Plateau's
Any suggestions will be greatly appreciated.....
5'4": Surgery 240/Current 135/Goal 140 = 105 lbs lost!!! BMI 22.5 I'm Normal
6 Years Later highest 198 / Current 176 / Goal 140
Hit Goal on 5/14/09 8 months out!
Join us on the Lightweights Board!
First: are you doing everything you can to maximize your weight loss? I find that I have to exercise 4x a week to maximize mine and keep my calories in the 600-800 range. Plus I need lots of protein and lots of fluids. (I am doing about 90 g of protein a day and 64 oz or more of fluids.)
So if you don't track your food, you might want to start. It's a good way to see if you are eating what you think you are eating.
Second: it could just be a case where you are losing fat tissue but you are gaining muscle and/or retaining water. If that's the case, your clothes will continue to get loose as you lose inches but the scale may not always reflect that loss. There isn't much you can do then besides grit your teeth and put the scale out of your mind
Actually, since you have a band, there could be a third thing... you may need another fill. As you lose weight, you tend to lose restriction.
HW - 225 SW - 191 GW - 132 CW - 122
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Starting BMI 40-ish or less? Join the LightWeights
Good luck. I hope the plateau has lifted for you by now.
Highest weight 250/ SW 233/Lowest Weight 135/Regain Highest 175/Current Weight 160
Hello, I completely understand your frustration. I too have hit several plateaus. I realized that protein and water play a MAJOR role in my weight lose. Everytime I hit a plateau, I had to stop and reaize what I ate for the wek. I questioned myself...Did I consume to many carbs??? Most of the time, I consumed aot more carbs then protein. When I realize what I did wrong, the very next day, I went on full blown protein and water. The funny part is, I just figured this all out last week! I was soooo tired of hitting plateaus...It really started to **** me off, so I did something about it. I am starting to learn what works for me and what doesnt work for me. Read this document titled, "Pouch Rules for Dummies". It is really hepful...
Pouch Rules for Dummies Pouch Rules (Please read credits at the end)
INTRODUCTION:
A common misunderstanding of gastric bypass surgery is that the pouch
causes weight loss because it is so small, the patient eats less. Although
that is true for the first six months, that is not how it works. Some
doctors have assumed that poor weight loss in some patients is because
they aren't really trying to lose weight. The truth is it may be because
they haven't learned how to get the "satisfied" feeling of being full to
last long enough.
HYPOTHESIS OF POUCH FUNCTION:
We have four educated guesses as to how the pouch works:
1) Weight loss occurs by actually "slightly stretching" the pouch with
food at each meal or;
2) Weight loss occurs by keeping the pouch tiny through never ever
overstuffing or;
3) Weight loss occurs until the pouch gets worn out and regular eating
begins or;
4) Weight loss occurs with education on the use of the pouch.
PUBLISHED DATA:
How does the pouch make you feel full?
The nerves tell the brain the pouch is distended and that cuts off hunger
with a feeling of fullness.
What is the fate of the pouch? Does it enlarge? If it does, is it because
the operation was bad, or the patient is overstuffing themselves, or does
the pouch actually re-grow in a healing attempt to get back to normal?
For ten years, I had patients eat until full with cottage cheese every
three months, and report the amount of cottage cheese they were able to
eat before feeling full. This gave me an idea of the size of their pouch
at three month intervals. I found there was a regular growth in the amount
of intake of every single pouch. The average date the pouch stopped
growing was two years. After the second year, all pouches stopped growing.
Most pouches ended at 6 oz., with some as large at 9-10 ozs.
We then compared the weight loss of people with the known pouch size of
each person, to see if the pouch size made a difference. In comparing the
large pouches to the small pouches, THERE WAS NO DIFFERENCE IN PERCENTAGE
OF WEIGHT LOSS AMONG THE PATIENTS. This important fact essentially shows
that it is NOT the size of the pouch but how it is used that makes weight
loss maintenance possible.
OBSERVATIONAL BASED MEDICINE:
The information here is taken from surgeon's "observations" as opposed to
"blind" or "double blind" studies,
but it IS based on 33 years of physician observation.
Due to lack of insurance coverage for WLS, what originally seemed like a
serious lack of patients to observe, turned into an advantage as I was
able to follow my patients closely. The following are what I found to
effect how the pouch works:
1. Getting a sense of fullness is the basis of successful WLS.
2. Success requires that a small pouch is created with a small outlet.
3. Regular meals larger than 1 ½ cups will result in eventual weight gain.
4. Using the thick, hard to stretch part of the stomach in making the
pouch is important.
5. By lightly stretching the pouch with each meal, the pouch send signals
to the brain that you need no more food.
6. Maintaining that feeling of fullness requires keeping the pouch
stretched for a while.
7. Almost all patients always feel full 24/7 for the first months, then
that feeling disappears.
8. Incredible hunger will develop if there is no food or drink for eight
hours.
9. After 1 year, heavier food makes the feeling of fullness last longer.
10. By drinking water as much as possible as fast as possible ("water
loading"),
the patient will get a feeling of fullness that lasts 15-25 minutes.
11. By eating "soft foods" patients will get hungry too soon and be hungry
before their next meal,
which can cause snacking, thus poor weight loss or weight gain.
12. The patients that follow "the rules of the pouch" lose their extra
weight and keep it off.
13. The patients that lose too much weight can maintain their weight by
doing the reverse of the "rules of the pouch."
HOW DO WE INTERPRET THESE OBSERVATIONS?
POUCH SIZE:
By following the "rules of the pouch," it doesn't matter what size the
pouch ends up.
The feeling of fullness with 1 ½ cups of food can be achieved.
OUTLET SIZE:
Regardless of the outlet size, liquidity foods empty faster than solid
foods. High calorie liquids will create weight gain.
EARLY PROFOUND SATIETY:
Before six months, patients much sip water constantly to get in enough
water each day, which causes them to always feel full.
After six months, about 2/3 of the pouch has grown larger due to the
natural healing process. At this time,
the patient can drink 1 cup of water at a time.
OPTIMUM MATURE POUCH:
The pouch works best when the outlet is not too small or too large and the
pouch itself holds about 1 ½ cups at a time.
IDEAL MEAL PROCESS (rules of the pouch):
1. The patient must time meals five hours apart or the patient will get
too hungry in between.
2. The patient needs to eat finely cut meat and raw or slightly cooked
veggies with each meal.
3. The patient must eat the entire meal in 5-15 minutes. A 30-45 minute
meal will cause failure.
4. No liquids for 1 ½ hours to 2 hours after each meal.
5. After 1 ½ to 2 hours, begin sipping water and over the next three hours
slowly increase water intake.
6. 3 hours after last meal, begin drinking LOTS of water/fluids.
7. 15 minutes before the next meal, drink as much as possible as fast as
possible. This is called "water loading,"
IF YOU HAVEN'T BEEN DRINKING OVER THE LAST FEW HOURS, THIS 'WATER LOADING'
WILL NOT WORK.
8. You can water load at any time 2-3 hours before your next meal if you
get hungry, which will cause a strong feeling of fullness.
THE MANAGEMENT OF PATIENT TEACHING AND TRAINING:
You must provide information to the patient preoperatively regarding the
fact that the pouch is only a tool: a tool is something that is used to
perform a task but is useless if left on a shelf unused. Practice working
with a tool makes the tool more effective.
NECESSITY FOR LONG TERM FOLLOW-UP:
Trying to practice the "rules of the pouch" before six to 12 months is a
waste. Learning how to delay hunger if the patient is never hungry just
doesn't work. The real work of learning the "rules of the pouch" begins
after healing has caused hunger to return.
PREVENTION OF VOMITING:
Vomiting should be prevented as much as possible. Right after surgery, the
patient should sip out of 1 oz cups and only 1/3 of that cup at a time
until the patient learns the size of his/her pouch to avoid being sick.
It is extremely difficult to learn to deal with a small pouch. For the
first 6 months, the patient's mouth will literally be bigger than his/her
stomach, which does not exist in any living animal on earth.
In the first six weeks the patient should slowly transfer from a liquid
diet to a blenderized or soft food diet only, to reduce the chance of
vomiting.
Vomiting will occur only after eating of solid foods begins. Rice, pasta,
granola, etc., will swell in time and overload the pouch, which will cause
vomiting. If the patient is having trouble with vomiting, he/she needs to
get 1 oz cups and literally eat 1 oz of food at a time and wait a few
minutes before eating another 1 oz of food. Stop when "comfortably
satisfied," until the patient learns the size of his/her pouch.
SIX WEEKS:
After six weeks, the patient can move from soft foods to heavy solids. At
this time, they should use three or more different types of foods at each
sitting. Each bite should be no larger than the size of a pinkie
fingernail bed. The patient should choose a different food with each bite
to prevent the same solids from lumping together. No liquids 15 minutes
before or 1 ½ hours after meals.
REASSURANCE OF ADEQUATE NUTRITION:
By taking vitamins everyday, the patient has no reason to worry about
getting enough nutrition.
Focus should be on proteins and vegetables at each meal.
MEAL SKIPPING:
Regardless of lack of hunger, patient should eat three meals a day. In the
beginning, one half or more of each meal should be protein, until the
patient can eat at least two oz of protein at each meal.
ARTIFICIAL SWEETENERS:
In our study, we noticed some patients had intense hunger cravings which
stopped when they eliminated
artificial sweeteners from their diets.
AVOIDING ABSOLUTES:
Rules are made to be broken. No biggie if the patient drinks with one meal
- as long as the patient knows he/she is breaking a rule and will get
hungry early. Also if the patient pigs out at a party - that's OK because
before surgery, the patient would have pigged on 3000 to 5000 calories and
with the pouch, the patient can only pig on 600-1000 calories max. The
patient needs to just get back to the rules and not beat him/herself up.
THREE MONTHS:
At three months, the patient needs to become aware of the calories per
gram of different foods to be aware of "the cost" of each gram. (cheddar
cheese is 16 cal/gram; peanut butter is 24 cals/gram). As soon as hunger
returns between three to six months, begin water loading procedures.
THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY:
1. Fill pouch full quickly at each meal
2. Stay full by slowing the emptying of the pouch. (Eat solids. No liquids
15 minutes before and none until 1 ½ hours after the meal). A scientific
test showed that a meal of egg/toast/milk had almost all emptied out of
the pouch after 45 minutes. Without milk, just egg and toast, more than ½
of the meal still remained in the pouch after 1 ½ hours.
3. Protein, protein, protein. Three meals a day. No high calorie liquids.
FLUID LOADING:
Fluid loading is drinking water/liquids as quickly as possible to fill the
pouch which provides the feeling of fullness for about 15 to 25 minutes.
The patient needs to gulp about 80% of his/her maximum amount of liquid in
15 to 30 SECONDS. Then just take swallows until fullness is reached. The
patient will quickly learn his/her maximum tolerance, which is usually
between 8-12 oz.
Fluid loading works because the roux limb of the intestine swells up,
contracting and backing up any future food to come into the pouch. The
pouch is very sensitive to this and the feeling of fullness will last much
longer than the reality of how long the pouch was actually full. Fluid
load before each meal to prevent thirst after the meal as well as to
create that feeling of fullness whenever suddenly hungry before meal time.
POST PRANDIAL THIRST:
It is important that the patient be filled with water before his/her next
meal as the meal will come with salt and will cause thirst afterwards.
Being too thirsty, just like being too hungry will make a patient
nauseous. While the pouch is still real small, it won't make sense to the
patient to do this because salt intake will be low, but it is a good habit
to get into because it will make all the difference once the pouch begins
to regrow.
URGENCY:
The first six months is the fastest, easiest time to lose weight. By the
end of the six months, 2/3 of the regrowth of the pouch will have been
done. That means that each present day, after surgery you will be
satisfied with less calories than you will the very next day. Another way
to put it is that every day that you are healing, you will be able to eat
more. So exercise as much as you can during that first six months as you
will never be able to lose weight as fast as you can during this time.
SIX MONTHS:
Around this time, our patients begin to get hungry between meals. THEY
NEED TO BATTLE THE EXTRA SALT INTAKE WITH DRINKING LOTS OF FLUIDS IN THE
TWO TO THREE HOURS BEFORE THEIR NEXT MEAL. Their pouch needs to be well
watered before they do the last gulping of water as fast as possible to
fill the pouch 15 minutes before they eat.
INTAKE INFORMATION SHEET AS A TEACHING TOOL:
I have found that having the patients fill out a quiz every time they
visit reminds them of the rules of the pouch and helps to get them "back
on track." Most patients have no problems with the rules, some patients
really struggle to follow them and need a lot of support to "get it", and
a small percentage never quite understand these rules, even though they
are quite intelligent people.
HONEYMOON SYNDROME:
The lack of hunger and quick weight loss patients have in the first six
months sometimes leads them to think they don't need to exercise as much
and can eat treats and extra calories as they still lose weight anyway. We
call this the "honeymoon syndrome" and they need to be counseled that this
is the only time they will lose this much weight this fast and this easy
and not to waste it by losing less than they actually could. If the
patient's weight loss slows in the first six months, remind them of the
rules of water intake and encourage them to increase their exercise and
drink more water. You can compare their weight loss to a graph showing the
average drop of weight if it will help them to get back on track.
EXERCISE:
In addition to exercise helping to increase the weight loss, it is
important for the patient to understand that exercise is a natural
antidepressant and will help them from falling into a depression cycle. In
addition, exercise jacks up their metabolic rate during a time when their
metabolism after the shock of surgery tends to want to slow down.
THE IDEAL MEAL FOR WEIGHT LOSS:
The ideal meal is one that is made up of the following: ½ of your meal to
be low fat protein, ¼ of your meal low starch vegetables and ¼ of your
meal solid fruits. This type of meal will stay in your pouch a long time
and is good for your health.
VOLUME VS. CALORIES:
The gastric bypass patient needs to be aware of the length of time it
takes to digest different foods and to focus on those that take up the
most space and take time to digest so as to stay in the pouch the longest,
don't worry about calories. This is the easiest way to "count your
calories." For example, a regular stomach person could gag down two whole
sticks of butter at one sitting and be starved all day long, although they
more than have enough calories for the day. But you take the same amount
of calories in vegetables, and that same person simply would not be able
to eat that much food at three sittings - it would stuff them way too
much.
ISSUES FOR LONG TERM WEIGHT MAINTENANCE:
Although everything stated in this report deals with the first year after
surgery, it should be a lifestyle that will benefit the gastric bypass
patient for years to come, and help keep the extra weight off.
COUNTER-INTUITIVENESS OF FLUID MANAGEMENT:
I admit that avoiding fluids at meal time and then pushing hard to drink
fluids between meals is against everything normal in nature and not a
natural thing to be doing. Regardless of that fact, it is the best way to
stay full the longest between meals and not accidentally create a "soup"
in the stomach that is easily digested.
SUPPORT GROUPS:
It is natural for quite a few people to use the rules of the pouch and
then to tire of it and stop going by the rules. Others "get it" and adhere
to the rules as a way of life to avoid ever regaining extra weight. Having
a support group makes all the difference to help those that go astray to
be reminded of the importance of the rules of the pouch and to get back on
track and keep that extra weight off. Support groups create a "peer
pressure" to stick to the rules that the staff at the physician's office
simply can't create.
TEETER TOTTER EFFECT:
Think of a teeter totter suspended in mid air in front of you. Now on the
left end is exercise that you do and the right end is the foods that you
eat. The more exercise you do on the left, the less you need to worry
about the amount of foods you eat on the right. In exact reverse, the more
you worry about the foods you eat and keep it healthy on the right, the
less exercise you need on the left. Now if you don't concern yourself with
either side, the higher the teeter totter goes, which is your weight. The
more you focus on one side or the other, or even both sides of the teeter
totter, the lower it goes, and the less you weigh.
TOO MUCH WEIGHT LOSS:
I have found that about 15% of the patients which exercise well and had
between 100 to 150 lbs to lose, begin to lose way too much weight. I
encourage them to keep up the exercise (which is great for their health)
and to essentially "break the rules" of the pouch. Drink with meals so
they can eat snacks between without feeling full and increase their fat
content as well take a longer time to eat at meals, thus taking in more
calories. A small but significant amount of gastric bypass patients
actually go underweight because they have experienced (as all of our
patients have experienced) the ravenous hunger after being on a diet with
an out of control appetite once the diet is broken. They are afraid of
eating again. They don't "get" that this situation is literally,
physically different and that they can control their appetite this time by
using the rules of the pouch to eliminate hunger.
BARIATRIC MEDICINE:
A much more common problem is patients who after a year or two plateau at
a level above their goal weight and don't lose as much weight as they
want. Be careful that they are not given the "regular" advice given to any
average overweight individual. Several small meals or skipping a meal with
a liquid protein substitute is not the way to go for gastric bypass
patients. They must follow the rules, fill themselves quickly with hard to
digest foods, water load between, increase their exercise and the weight
should come off much easier than with regular people diets.
SUMMARY:
1. The patient needs to understand how the new pouch physically works.
2. The patient needs to be able to evaluate their use of the tool, compare
it to the ideal and see where they need to make changes.
3. Instruct your patient in all ways (through their eyes with visual aids,
ears with lectures and emotions with stories and feelings) not only on how
but why they need to learn to use their pouch. The goal is for the patient
to become an expert on how to use the pouch.
EVALUATION FOR WEIGHT LOSS FAILURE:
The first thing that needs to be ruled out in patients *****gain their
weight is how the pouch is set up.
1) the staple line needs to be intact;
2) same with the outlet and;
3) the pouch is reasonably small.
1) Use thick barium to confirm the staple line is intact. If it isn't,
then the food will go into the large stomach, from there into the
intestines and the patient will be hungry all the time. Check for a little
ulcer at the staple line. A tiny ulcer may occur with no real opening at
the line, which can be dealt with as you would any ulcer. Sometimes,
though, the ulcer is there because of a break in the staple line. This
will cause pain for the patient after the patient has eaten because the
food rubs the little opening of the ulcer. If there is a tiny opening at
the staple line, then a reoperation must be done to actually separate the
pouch and the stomach completely and seal each shut.
2) If the outlet is smaller than 7-8 mill, the patient will have problems
eating solid foods and will little by little begin eating only
easy-to-digest foods, which we call "soft calorie syndrome." This causes
frequent hunger and grazing, which leads to weight regain.
3) To assess pouch volume, an upper GI doesn't work as it is a liquid. The
cottage cheese test is useful - eating as much cottage cheese as possible
in five to 15 minutes to find out how much food the pouch will hold. It
shouldn't be able to hold more than 1 ½ cups in 5 - 15 minutes of quick
eating.
If everything is intact then there are four problems that it may be:
1) The patient has never been taught the rules;
2) The patient is depressed;
3) The patient has a loss of peer support and eventual forgetting of
rules, or
4) The patient simply refuses to follow the rules.
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 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.
2) 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 a while 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.
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 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.
4) TRUE NONCOMPLIANCE:
The most difficult problem is a patient who is truly noncompliant. 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 noncompliance that causes this attitude. A truly noncompliant 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.
This rewrite was done exclusively for the people of this spotlight obesity
support group. It should not be sold for any reason.
"Dummies" version rewritten by Sally Perez
Original article written by:
Mason. EE, Personal Communication, 1980. Barber. W, Diet al, Brain Stem
Response To Phasic Gastric Distention.
Am J. Physical 1983: 245(2): G242-8 Flanagan, L. Measurement of Functional
Pouch Volume Following the Gastric Bypass Procedure. Ob Surg 1996; 6:38-43
Pouch Rules for Dummies
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