Rules of the Pouch

Taken from a handout given to me by my surgeon at the 6+ mo out stages: RULES OF THE POUCH 1. Time meals five hours apart to prevent between meal hunger. 2. Eat finely cut meat and raw or slightly cooked veggies with each meal. 3. Eat the entire meal in 5-15 minutes. A 30-45 minute meal will cause failure. 4. No liquids for 1 1/2 hours to 2 hours after each meal. 5. After 1 1/2 to 2 hours, begin sipping water and over the next three hours slowly increase water intake. 6. Three (3) hours after last meal, beging 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. AVOID ABSOLUTES: Rules are made to be broken. It is no crime if a 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 overindulges at a party - that's OK because before surgery, the patient would have binged on 3000 to 5000 calories and with the pouch, the patient can only binge on 600-1000 calories max. As long as this is not a consistent pattern and the patient returns to the rules, they need not chastise themselves. 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 beofre and none until 1 1/2 to 2 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 1/2 of the meal still remained in the pouch after 1 1/2 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 15-25 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 8-12oz. 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 nauseaus. 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 grow. THE IDEAL MEAL FOR WEIGHT LOSS The ideal meal is one that is made up of the following: 1/2 of your meal to be low fat protein, 1/4 of your meal low starch vegetables and 1/4 of your meal solid fruits. This type of meal will stay in your pouch a long time and is good for your health. SUPPORT GROUPS It is natural for a 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 wway 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. WHAT NOT TO DO: A 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. Several small meals or skipping a meal with a liquid protein subsititue 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. IMPORTANT CONTRIBUTORS OR WEIGHT LOSS FAILURE 1) 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 the attention of a bariatric surgeon, she was treated for her disease, which helped her to begin walking one mile per day. her pouch with a 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 ficused on food as she was, and feelign the best she has felt since the first months after her operation 15 years ago. 2) DEPRESSION: Depression is a stong 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 you begin to gain weight due to depression, get coundeling quickly. Refocus on the pouch rules and try to add a little exercise every day. 3) 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 that what they are doing is wong and KNOW that they just need to get back on track. Even if "refresher courses" are available, they may not attend because they KNOW what the course is going to say, they know the rules and how they are breaking them. Once these patients return to their support group, and keep in contact with their surgical peers, it makes it much easier to return to the rules of the pouch and get their weight under control once again.

Hi Paula I just love this can you please send me a copy by email [email protected] thank again Judith N

Ok who out there can eat a meal in 5 to 15 minutes. I sure cant unless its a liquid meal. I would surely hurl. I guess thats one way to lose. lol Tammy O

I can eat a meal very quick. I can drink really quick to. I have never had a problem with that. Take Care Barb

the fast eating thing is very comforting to me, because I've always been a fast eater. I thought it might be a problem, but not according to this. I don't fully understand the water loading thing...but want to try. Does anyone do this regularly???

The reason for water loading is two-fold: 1) By water-loading, you have no reason/excuse for wanting to drink fluid with meals because you're already hydrated - this allows food to stay in your pouch longer (instead of getting washed down by a drink with your meal), leaving you satisfied longer with less food. 2) By filling up on water before the meal, the intestine has something to deal with, and is less likely to want/need the food right away, and you make sure that you get in your fluid. It doesn't apply to me, as I had a different surgery.

Okay, the one rule I have always broken is the drinking with meals. I do...I have never been able to eat without drinking...I pray everyday that it doesn't mess my surgery up...so far, it hasn't.... ~~em