How to be a Successful "Loser" after Gastric Bypass Surgery

Obesity is a chronic disease. Although there is no cure for it, treatment does exist. Your treatment may include gastric bypass surgery; however, this is no cure for obesity. Surgery is a tool to help you lose weight. It is in addition to diet and exercise, not a replacement for diet and exercise. It does not work by magic! Simply stated, gastric bypass surgery is a tool that you must learn to use properly.

Body weight is determined by the ratio between "calories in" versus "calories out." The laws of thermodynamics are constant! One pound of body fat represents 3500 calories that were consumed, but never used. Therefore, in order to lose one pound per week, 500 calories must be subtracted from the "calories in" side, or 500 calories must be added to the "calories out" side of the ratio. There are many different types of diets and exercise programs that can facilitate such a calorie deficit. Gastric bypass surgery is also a big help in producing such a calorie deficit.

Much can be learned from people who have lost significant amounts of weight and kept it off for long periods of time, through both surgical and non-surgical means. For instance, the National Weight Control Registry is an ongoing study investigating the common characteristics and behaviors of people who have lost at least 30 pounds and kept it off for at least a year. Currently over 2,900 people in the United States are enrolled, and most have lost approximately 70 pounds and have maintained that weight loss for 5 or 6 years. These people have achieved their weight loss through various methods (professional/medical help, commercial programs like Weigh****chers, dieting on their own, surgery, etc.). Also, research has been done and books have been written specifically about what gastric bypass patients do to lose as much weight as possible after surgery. One book in particular was written by a gastric bypass patient, Colleen Cook, and is called The Success Habits of Weight Loss Surgery Patients. It is geared more toward the person who has already had bariatric surgery, but is wonderful for everyone who is even considering bariatric surgery to read.

Some of the most common success habits shared between people who have lost and maintained significant amounts of weight have to do with self-monitoring behaviors and personal accountability, portion control, diet and nutrition, physical activity and vitamin/mineral supplements, which are of critical importance to the gastric bypass patient.

SELF-MONITORING AND PERSONAL ACCOUNTABILITY

1. Weigh yourself.
Approximately 75% of the National Weight Control Registry (NWCR) participants weigh themselves at least once a week. Weighing yourself once a week is ideal: more often becomes a little obsessive, less often makes it too easy to slip!

• Be consistent about weighing yourself. Weigh yourself on the same day of the week, same time of day, on the same scale, in the same amount of clothing.
  
  
• Have a weight loss goal in mind and keep a weight chart or graph. Remember, "...if you don't know where you're going, then any road will take you there." (Cook, 21)
  
  
• Ask yourself these questions to decide what a good goal is for you:
  
  1. If you've ever felt good about your weight, what was it?
  2. Talk to your doctor or a registered dietitian about what a healthy weight range or BMI (body mass index) would be for you.
  3. At what weight do you think you'd be comfortable?
  4. What size do you think is right for you based on your height and your body type? Do you know anyone else who is of a similar height and frame as you? What size do they wear and what do they weigh?

2. Keep a food diary!
About half of the NWCR participants still count calories and/or grams of fat to maintain their weight loss. They know how many calories they're consuming. The best way to keep track of this is to keep a food diary.

PORTION CONTROL

1. Know how big (or small) your new stomach is and how much food it can hold.
After gastric bypass surgery your stomach is about the size of a thumb and can hold about 4oz. (1/2 cup) of food at a time.

2. Eat slowly enough to recognize the feeling of fullness; stop eating when full.
Try to make each meal last 20 minutes. See your handout on "Addressing Your Eating Habits" for more tips on how to eat slower.

3. Aim for satiety.
Understand that hunger is what you feel when your stomach growls - it is a true physiological need for nourishment. Appetite is simply a desire for food - what you feel when driving past your favorite restaurant or when you smell your favorite food cooking. Satiety is the feeling of being full and satisfied after eating, and is something you want to feel after eating. Satiety is affected by many things including hunger, cravings, social situations, emotions, food choices and eating habits.

High fiber foods slow down the rate at which food leaves the stomach, thereby creating a longer-lasting feeling of fullness. Incorporate beans/lentils, vegetables, fruits and high fiber breads (at least 2g. fiber per slice) and cereals (at least 6g. fiber per cup) in your meals daily. High protein foods are also satisfying, so be sure to include meats, fish, poultry, dairy and beans/lentils in your daily meals.

After meals, your stomach wall should be slightly distended, or stretched, which also creates satiety. This stomach wall distention is not experienced after a snack or grazing episode. It is something that happens after a balanced, well-planned, preferably prepared-at-home meal. In other words, eat 3 small meals a day and avoid snacking and grazing. Grazing is a behavior common to people who are disappointed with their weight loss and/or *****gain their weight after gastric bypass surgery. Ask yourself these questions when conquering your grazing habit:

• What time of day is grazing most likely to occur?
• What else is happening while grazing (television, studying, etc.)?
• What are you grazing on and how did you get it?
• What type of food do you crave when you graze or are tempted to graze (chewy, crunchy, sweet, salty)?
• How do you feel when you graze or are tempted to graze (bored, tired, stressed, anxious)?

To further slow down the time it takes for food to empty out of your stomach, avoid drinking with meals and for at least _ hour after meals. Also, avoid high calorie drinks because they do not satisfy. Instead, stick to calorie-free beverages and low-fat or fat-free milk between meals.

DIET AND NUTRITION

2. Eat "nutrient-dense" foods.
When your stomach is only the size of a thumb and you can only fit 4 ounces of food in it at a time, you must make every bite count! Foods that are nutrient-dense include lean meats, poultry, and fish; low-fat dairy products; fruits and vegetables; and high fiber breads and cereals. Read Nutrition Facts panels to find bread with at least 2g. of fiber per slice, and cereal with at least 6g. of fiber per cup. Generally, sweets, snack foods, fried foods, soda pop and juices are not considered nutrient-dense, just calorie-dense!

3. Ensure adequate protein intake.
Adequate protein intake is critical for gastric bypass patients. There should be at least 2 ounces of a high protein food at all three meals everyday, and the high-protein portion of the meal should be eaten first before moving on to any other kinds of food. Your protein intake goal after surgery will be 50-60 grams a day. This is usually not difficult to reach, as long as you focus on eating a high protein food at each meal.

There are two different kinds of protein: complete and incomplete. Complete protein is also known as high biological value protein and most commonly is found in foods that come from animals. It is called "complete" protein because it has all of the essential amino acids in it. Low-fat foods that are excellent sources of high biological value (HBV) protein and should be included in your diet everyday are:

• white meat chicken and turkey (not fried)
• fish and shellfish (not fried)
• eggs, egg whites and egg substitutes
• lean cuts of beef (ground round, sirloin, flank, tenderloin, rib/chuck/rump roasts)
• lean cuts of pork (fresh ham, Canadian bacon, center loin chop, tenderloin)
• veal or lamp chops and roasts
• lean deli meats (turkey, ham, roast beef)
• reduced fat cheeses (parmesan, mozzarella, ricotta, cottage cheese)
• venison, duck and pheasant

Though good sources of complete protein, the following foods are high in fat and calories and should be reserved for special occasions only:

• bacon and sausage
• spareribs
• kielbasa
• cheese (American, cheddar, Swiss, provolone)
• bologna, salami and pepperoni
• hot dogs
• fried chicken, dark meat chicken and turkey
• fried fish and shellfish
• all meats that are fried

Incomplete protein does not contain all of the essential amino acids, and is usually found in foods that come from plants. Incomplete protein definitely counts toward your total protein intake for the day; you just want to place more emphasis on the HBV protein. Sources of incomplete protein include:

• beans and lentils
• nuts and peanut butter
• vegetables
• starches (breads, cereals, pasta, grains, etc.)

Soy is one exception! Soy foods are great sources of complete protein, even though soy is a plant food. Go ahead and include soy milk, tofu, tempeh, soybeans, soy cheese and other soy-based foods in your diet regularly and count them as high biological value proteins.

There is also a wide variety of protein supplements that can count toward your total protein intake. When choosing supplements, be mindful of the calories per serving. Try to stay below 200 calories per supplement. Also, remember that supplements should supplement your food intake. In other words, focus on food sources of protein first, and then eat one protein bar or drink one shake a day just to make sure you are getting enough. Finally, protein bars may be more filling and satisfying than shakes, because solid foods produce a greater feeling of satiety than liquids.

4. Eat breakfast!
Approximately 78% of NWCR participants eat breakfast seven days a week, and 90% of them eat it at least four days a week. Remember, most of these participants have lost 70 pounds and have kept it off for five or six years. Breakfast is something you eat within one or two hours after waking, and there seems to be something about it that helps people maintain their weight. Perhaps eating breakfast helps you to choose lower calorie foods throughout the rest of the day, or maybe eating breakfast gives you more energy to exercise later on in the day. Whatever the case may be, eating breakfast is a common habit among people who have maintained a significant amount of weight loss.

PHYSICAL ACTIVITY

Research demonstrates consistent correlations between physical activity, self-monitoring behaviors and maintenance of weight loss. It's been proven time and again that people who exercise, weigh themselves regularly and keep track of what they eat tend to maintain their weight loss. How many times have you heard, "eat less, exercise more" when you are trying to lose weight? It turns out to be true after all!

The biggest risk of exercise is to not start. Any activity is better than none at all. Start with 20-30 minutes, three or four days a week, and take time to build up to 30-60 minutes, five to seven days a week. Explore a variety of activities to find something you enjoy so that you don't get bored. Confront your reasons for not exercising and overcome them. Be willing to exercise for yourself, for your health and by yourself, if necessary.

If you are having trouble motivating yourself, try one of these tricks:

• Choose a place on the map you'd like to visit and find out how many miles away it is. Then, theoretically, walk there. Every mile you walk counts as one more mile toward your destination! Or, consider one minute of exercise as one mile toward your destination.
• Write down ten different rewards on ten pieces of paper and put them in a bag. If you meet your exercise goal(s) at the end of the week or the month, pick one reward out of the bag. Keep in mind, though, that food should never be part of any reward.
• Activity Bank: Place $1 in a bank every day that you meet your exercise goal(s). Do not place any money in the bank on the days that you do not meet your exercise goal(s). At the end of the month, use the money to treat yourself to a facial, manicure, tickets to a sporting event, etc. Again, don't use the money to go out to eat!

VITAMIN AND MINERAL SUPPLEMENTS

After surgery, your small stomach pouch produces less of a chemical called intrinsic factor, which is needed for vitamin B12 digestion and absorption. Therefore, you need a vitamin B12 supplement that gets absorbed directly into the bloodstream, not the digestive tract. You have two options: a B12 shot at your primary care physician's office once a month, or sublingual (under the tongue) lozenges. The lozenges can be found at GNC, Vitamin World and on the Internet. A 500-1000mcg lozenge everyday is sufficient, or you can take a 2000-5000mcg lozenge once a week.

After having gastric bypass surgery, the first three to five feet of your small intestine will be "bypassed," meaning no food passes through it. This part of the small intestine is, or was, one of the primary absorption sites for two essential minerals: calcium and iron.

You will take 1000mg of calcium every day after surgery. Select a chewable supplement like Viactiv® or Caltrate® 600 Plus Chewable and take one supplement, twice a day. Calcium is best absorbed with food, but it should be taken two hours apart from iron, as the absorption of these two nutrients interfere with one another.

Iron needs to be taken just once a day. It does not come in a chewable form, but the pill is small enough that you should be able to swallow it without difficulty. Iron is also best absorbed when taken with food, but must not be taken with the calcium supplement. Take your iron and calcium at least two hours apart from one another.

Since nausea and constipation are common side effects of iron supplements, we recommend iron supplements that come in the form of ferrous fumarate or ferrous gluconate, like Fergon or Ferro-Sequels®. Still, some people can only take their iron supplements every other day, which is fine.

Sample vitamin schedule:

After a few months of taking chewable supplements, you may switch to solid pill forms. These vitamin and mineral supplements must be taken every day for the rest of your life. They are not optional! Be sure to visit the West Penn Bariatric Surgery Center at least yearly (after the first year) to get a script for blood work to be done to make sure that you are not becoming malnourished.

Remember, "...(surgery) provides a tool which, if used PROPERLY, will help you gain and stay in control of that very basic principle: Calories-In versus Calories-Out. You and ONLY you are responsible for what you eat, when you eat, and how much you eat." (Cook, 16).

RECOMMENDED READING:

The Success Habits of Weight-Loss Surgery Patients by Colleen M. Cook, published in 2003 by Bariatric Support Centers International in Salt Lake City, Utah. www.bariatricsupportcenter.com

Gastric Bypass Cookbook:

Culinary Classics: Essentials of Cooking for the Gastric Bypass Patient by Chef David Fouts, published in 2003 by U.S. Bariatric in Fort Lauderdale, Florida.