Back to Basics for Weight Loss Surgery Patients

With the new year well on it’s way, many of us are starting to think about 2017 resolutions like re-start weight loss, getting back to the gym, or cutting out junk food. Before deciding on a resolution, let’s review the basics. What does a weight loss surgery patient need to consider for success?  I’ve spoken to some bariatric patients who believe they no longer need to follow the “Bariatric Basics” because they are years out from surgery. Unfortunately, this is simply not true. In fact, it can be a  reason for weight gain and complications in the long term. 

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Below are six principles, or “bariatric basics” to followed for life after weight loss surgery. These principles were put together by Colleen M. Cook, a bariatric patient who has had her share of struggles and successes. Her book, includes the following principles as well as her tips and success stories of other patients. The book, “The Success Habits of Weight Loss Surgery Patients” is chocked full of tips and interesting stories.

Principle 1: Personal Accountability

You and only you are in control of what you eat and how frequently you exercise. Your dietitian or bariatric surgeon can't plan your meals or take you to the gym. So take a minute and think, what are you doing to stay in control of your weight everyday?

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Regular weighing and charting is the best way to stay in control. Let say you gain a half pound every month, not much weight at all. You wouldn’t notice in your clothes, and maybe not see it on the scale. But, a half pound a month for a whole year is 6 pounds. After 6 years, that's 36 added pounds. By weighing regularly and charting weight trends, it would be easy to notice a slow upward trend. Loosing 2 pounds after 4 months of weight gain is much easier than losing 36 pounds after 6 years of weight gain. 

How frequently you weigh in is up to you. It could be weekly, bi-weekly, or even monthly. Everyday might be overkill, but make sure it is always the same day of the week, at the same time, and on the same scale. Many chose to weigh in first thing Monday morning on their home scale, without clothes. For others, who need accountability, weigh in at the gym with a trainer or at the doctor’s office. 

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Having a clear, goal weight is important. Write the number down and reflect on is as weight is lost. It's okay to change the goal as you get closer to it. Some find that their original number was lower than they’re able to attain. Others may realize they’re able to reach a lower weight than originally thought. If the goal of weight loss surgery is to eliminate diabetes, obstructive sleep apnea (OSA), etc that’s okay. There will be a weight at which the diabetes, OSA, are managed. Anything above that weight will trigger problems with the disease again. Keep your goals written down in a place where you will see them daily. Before making any decision, ask yourself, will this help me reach my goal? 

Finally, determine a warning weight. After weight loss has slowed or stopped, the next goal becomes weight maintenance. Maintenance is very different. More calories can be eaten. Skipping the gym may occur more frequently. But be careful because weight gain can happen. Determine a weight, maybe 5-to-15 pounds heavier than your maintenance weight, as the point when you get back into weight loss mode. This allows you to enjoy some down time from weight loss, but triggers a re-start once a certain number is reached. 

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Principle 2: Portion Control

The point of surgery is to create a smaller stomach pouch. When a meal is eaten, the pouch expands, causing the patient to feel full sooner than they would without surgery. When surgery doesn’t work, it can mean the patient isn’t using the pouch correctly. If too little is eaten, the pouch doesn’t stretch and the patient never feels full. When the patient frequently eats soft foods or relies mostly on protein shakes/liquids meals, the pouch doesn’t stretch. 

Absent the feeling of fullness there is nothing to prevent snacking, grazing, and weight gain. On the other hand, if the patient constantly overeats, their pouch extends too far. The more frequently they overeat, the more likely they will be able to fit in too much food, leading to weight gain. 

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Here is the key; patients one-to-six months out from surgery can generally only eat 2-4 oz (1/4-1/2 cup) at a time. The pouch will naturally get larger with time. Anyone more than six months out from surgery can generally eat 6-8 oz (3/4 to 1 cup) at a time. If a patient can eat more than 10-12 oz at a time, weight gain will most likely occur. 

Eat at meal time, eat enough to feel full, and eat foods that will keep the pouch full for a while. Set aside three meal times a day. During mealtimes, sit down to eat. Put your food on a plate. Do not watch TV, surf the internet, or read while eating.  It’s called mealtime, not media time. Distracted eating leads to over-eating and pouch over-stretching. Foods that will fill you up and keep you full are protein and fiber. Drinking during a meal time can make food leave the pouch too soon causing hunger to develop too soon. No eating and drinking at the same time is suggested for a LIFETIME. Just because it no longer hurts to eat and drink at the same time doesn’t mean you should do it. 

Eat slowly and chew very well. Once a meal causes the pouch to stretch, it takes 20 minutes for that signal to reach our brains. Therefore, meals need to last for at least 20 minutes in order for us know if we have eaten enough or overeaten. Slow down by chewing every bite to liquid consistency. Take a deep breath between bites to re-focus on the meal. You may notice that after a deep breath, you’ve become satisfied. Do not need to continue eating. 

If grazing happen, and it will, learn from yourself. When are you feeling the need to graze?  What are you craving at the time? Maybe sweets, like a candy bar. What are you doing at this time? What could you do to stop the craving? Maybe take a short walk around the building or drink some water instead. If the craving doesn’t go away are you prepared to satisfy that craving with a healthy alternative? Keeping healthy snacks like pistachios or an apple with peanut butter on hand is a good idea. (Note: all these maybes are my real life struggle).

Principle 3: Nutrition

The order in which foods is eaten makes a difference. Protein should always come first, it's what keeps us full and satisfied after a meal. Protein malnutrition leads to muscle loss, weakened immune systems, and hair loss. Choose lean proteins like fish, turkey, chicken, and tofu most often. Protein foods like non-fat dairy, cheese, eggs, lentils, beans, nuts, seeds, and lean pork should come in as second choices. Keep higher calorie meats such as beef, lamb, bacon, sausage, and ham to a minimum. Try to cook these in a roaster, oven, slow cooker, or in boiling water. Avoid using butter or oil if at all possible. 

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After protein, a vegetable or fruit should come second. Fiber from these foods helps to slow down digestion, making fullness last longer. Finally, complete the meal with a carbohydrate. You don’t have to eliminate carbohydrates (rice, corn, potatoes, pasta, bread, tortillas) from the diet, but should only take a couple bites. In the first few month after surgery, 3 bites of protein and 1 bite of vegetables counts as a meal. As the patient is able to eat more, they should try for 3-4 oz of protein and 1/4 to 1/2 cup of vegetables at the meal. If the meal lasted 20 minutes, all the food was chewed well, the meal was eaten with no distractions and there is still room for more, a couple bites of carbohydrate will not hurt. 

Principle 4: Fluid Intake

Look at your urine every time you use the restroom. It should be clear to very light yellow. All adults should be getting around 64 oz of fluid each day, which can be a struggle after weight loss surgery. The stomach is too small to eat and drink at the same time and to chug a significant amount of fluid all at one time. It does take practice to remember to bring a water bottle wherever you go and to actually drink the water when you have it. Correct fluid balance in our bodies leads to better muscle tone, improved hair and skin quality, elimination of waste and toxins, increased energy, appetite suppression, and weight maintenance. Everyone has experienced mild dehydration which includes thirst, dry lips, dry mouth, and even hunger. Moderate dehydration would also cause sunken eyes, and skin that doesn’t bounce back after touch. If these signs occurs, it may be time to head to the Emergency Room for a IV bag of fluids. 

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Weight loss surgery patients need to take great caution with other fluids such as caffeine, carbonation, and alcohol. Every surgeon has different recommendations for these type of beverages. We recommend avoidance for at least six months after surgery. If caffeine is going to be introduced, watch how much is being consumed. Caffeine can lead to dehydration, increased stress, and elevated blood pressure, all which can lead to weight gain. Caffeine should be limited to about 2 cups (16 oz) of coffee a day, or one Grande size from Starbucks. 

Carbonation can be difficult after surgery as well. If the carbonation that you like is from a soda, all your giving yourself is calories and chemicals. Don’t waste your money and energy on those appetite stimulating drinks. However, six months after surgery, carbonated water may be used to help with hydration. Simply be aware how much is consumed at one time. A large gulp could cause stretching of the connection between the stomach and the small intestine. This connection is usually made tight by the surgeon to hold food in the stomach longer. Once this has been stretched, the patient may feel hunger sooner than they should. 

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As for alcohol, any bariatric patient should be careful. High calories in alcoholic beverages will prevent weight loss when consumed more than a couple times a week. Calories range from 100-200 for one bottle of beer or glass of wine. 

Calories in one shot of hard liquor range from 60-80, this isn’t including sugary mixers used with them. Also, absorption of alcohol occurs faster than the average person. A bariatric patient can become dangerously intoxicated on less alcohol than the average person. This rapid alcohol absorption may increase the risk for developing alcoholism after weight loss surgery. Another reason for the high risk of alcoholism is the potential for addiction transfers. When someone addicted to food is no longer able to eat, turning to alcohol is very easy and comforting. 

Principle 5: Exercise

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Everyone knows they must exercise to lose and maintain their weight. The problem is getting up and doing it. Take responsibility for your exercise. Figure out what is preventing you from exercising and change it. Make it become a habit, something that you cannot live without doing. The author of these principles, Colleen Cook, determined three motivating factors that everyone must have to make exercise a habit. 

1. Exercise for yourself, by yourself. If you only exercise because your gym buddy is working out, you won't continue when they are not at the gym. 
2. Exercise for your health. If you don’t believe exercise will strengthen your muscles, improve your posture, make you feel better, and reduce risk for disease, you wont do it. 
3. Exercise because you enjoy it. I’ve had people tell me they hate walking on the treadmill for 30-minutes everyday but that is the only exercise they get. I am never surprised to find out they only do it once or twice a week instead of 4 to 6 days a week. Find something more fun to do. Join a hiking club, take a yoga class, put together your favorite playlist and dance for an hour, or make a visit with a personal trainer. Find something you like and do it. 

Doing the same exercise day in and day out will cause burn out. Find a couple different things you like and vary it. Chose both aerobic exercises and strength building exercises in the same week. During aerobic exercises, you should become out of breath. This will improve the heart and lungs, burn body fat, increase energy, decrease stress, anxiety, and depression, and improve sleep and mood. Strength building exercises should leave your muscles sore the next day. Strength building increases balance, flexibility, mobility, bone density, causes the body to burn more calories even after the work out, and improve self-esteem. 

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Principle 6: Vitamins

I see vitamin deficiencies everyday. Some have a deficiency before surgery, others develop one shortly after surgery, and others develop years later. For those that develop years after surgery, the deficiency usually becomes very severe. The first year after surgery patients are typically good at taking vitamins throughout the day. The first two years, blood tests may come back perfect. As time goes by, vitamins are forgotten and labs don't get checked. Then patients starts to feel tired, no big deal right? Everyone gets busy and tired from life. Eventually they start to forget things. Again, no big deal, we all forget things as we age. Depression starts to set in, they may lose their appetite or have digestive issues. Finally, the toes and fingers start to get tingly, it is hard to stay balanced. Now they realize something is wrong and head to the doctor. All of these symptoms are found in a B12 deficiency. A year or two of tiredness, forgetfulness, and depression can be easily prevented by taking high quality vitamins everyday and having labs checked every year. 

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Take responsibility for your health. Understand that after weight loss surgery you will have to take vitamins everyday, multiple times a day, for the rest of your life. The sleeve gastrectomy and gastric bypass procedures both reduce the acid produced in the stomach. Some vitamins need acid to become active. Without the stomach acid, patents will not get these vitamins without supplementation. In the gastric bypass procedure, the first part of the small intestine is skipped. This is where most vitamins are absorbed. Gastric bypass patients will not absorb these vitamins. 

If you're prone to forgetting vitamins, leave little stashes around the house, in your car, in your desk or locker at work, on the kitchen counter, on the bathroom counter. Chances are, you will see the stash at some point and remember to take the vitamin. Finally, choose a good quality vitamin. Purchasing a cheap vitamin may mean you short yourself from important nutrients. Any vitamins made specifically for bariatric patients such as Bariatric Advantage Vitamins or Celebrate Vitamins will be good quality. Otherwise, look for vitamins that are USP certified or tested by the FDA. Current laws do not require testing of vitamins. This means that a cheap brand of vitamins may not contain what the bottle says it does. 

If you want to read more about what others have done to successfully keep the weight off after bariatric surgery, I urge you to read Colleen Cook’s book “Success Habits of Weight Loss Surgery Patients.” The author now works as a motivational speaker for the Bariatric Support Center, you can find them and other resources online at 
www.bariatricsupportcenter.com. 

You can also join some social media support groups on Facebook. Some groups you may request to join are: 

Success Habits Discussion Group/ Bariatric Support Group/ Hope and Help for the Pain of Regain. 

Dr. Bobby also has his own private support group on Facebook. If Dr. Bobby performed your surgery and have not been added as a member to this group, please notify our office so that we may add you. 

Recipe Corner

Glazed Cocktail Meatballs

Total time: 1 hour 30 minutes (can make ahead and freeze as needed)

Makes 13 servings (3 meatballs each), that is 13 meals you have prepped and can freeze!

Ingredients:

1 cup water

1/4 cup uncooked burger

1 pound ground turkey

1/4 cup finely chopped onion (chop in a food processor to save time)

2 teaspoons chopped fresh thyme

2 teaspoons Worcestershire sauce

1 teaspoon kosher salt

1/4 teaspoon black pepper

2 garlic cloves, minced

1 large egg

1 tablespoon plus 1 tsp olive oil

Cooking Spray

5 tablespoons organic grape jelly

2 tablespoons fresh orange juice 

1 teaspoon unsalted tomato paste

1/4 teaspoon ground red pepper

Directions:

1. Combine water and burger in a small bowl. Let stand 30 minutes; drain. Combine bluger, ground turkey, and next 8 ingredients (through olive oil) in and large bowl, gently mix with hands until combine. Cover and chill 45 minutes. Shape into 39 (1-inch meatballs)
2. Preheat over to 425°F. Arrange meatballs in an even layer in a 13- x 9-inch baking dish coated with cooking spray. Bake in preheated oven until lightly browned and cooked through, about 15 minutes.
3. Meanwhile, bring grape jelly and the remaining ingredients to a simmer in a small saucepan over medium heat, and simmer for 5 minutes. Remove from heat, and let stand 5 minutes. Place meatballs in a large bowl. Add the jelly mixture; toss gently to coat. Serve immediately. (Save this step for the day of serving if you are prepping ahead of time.)

I love meatballs as a bariatric food. They are easy to freeze and pull out whenever you’re ready for a small meal. Perfect for the rest of the family too, they may just eat a few more than you. This recipe has been adapted from my favorite healthy recipe website: http://www.cookinglight.com/recipes/glazed-cocktail-meatballs

Buttery Roasted Cauliflower

Time: 25 minutes

Serves: 4

Ingredients: 

4 cup small cauliflower florets

2 large shallots, cut into wedges 

cooking spray

1 tablespoon canola oil

1 tablespoon butter, melted

3/8 teaspoon kosher salt

1/4 teaspoon black pepper

1 tablespoon chopped fresh chives

fresh tarragon leaves (optional)

Directions: 

1. Place a large pan in over, preheat oven to 450°F. (Leave pan in oven as it preheats.)
2. Place cauliflower and shallots on preheated pan; lightly coat vegetables with cooking spray, and toss with oil. Bake at 450°F until browned and tender, about 15 minutes. 
3. Drizzle with butter; toss to coat. Sprinkle with salt and pepper; top with chives and tarragon, if desired.

A vegetable should be included at every dinner. Cauliflower is versatile and inexpensive year round. Recipe credit: http://www.cookinglight.com/recipes/buttery-roasted-cauliflower

Broiled Salmon with Lemon

Time: 30 minutes

Serves: 4

Ingredients: 

1 tablespoon extra-virgin olive oil

1 teaspoon grated lemon rind, plus 1 Tbsp fresh juice (from 1 lemon)

1 teaspoon Worcestershire sauce

1 (12oz) salmon filet or 4 (3-4oz) fillets

1/4 teaspoon kosher salt

1/4 teaspoon black pepper

Directions: 

1. Combine oil, rind, juice, and Worcestershire sauce in a shallow dish. Place fillets, skin side up in dish. Let stand 15 minutes. 
2. Pre-heat broiler with over rack 6 inches from heat. Place fillets, skin side down, on a foil-lined baking sheet, Sprinkle with salt and pepper. Broil to desired degree of doneness, 8-10 minutes. Remove fillets from foil using a metal spatula. 

Using the broiler is a great way to heat the house during the cold winter months. Lemons will be in season within the next couple of months, so use them while they are fresh from the trees. 

Recipe Credit: http://www.cookinglight.com/recipes/broiled-salmon-lemon

Lemony White Bean-and Arugula Salad

Time: 8 minutes

Serves: 4

Ingredients: 

2 Tablespoons extra-virgin olive oil

1 teaspoon grated lemon rind plus 2 Tbsp fresh juice (from 1 lemon)

1 teaspoon Dijon mustard

3/8 teaspoon kosher salt

1/4 teaspoon black pepper

1 (15oz) can unsalted cannelloni beans, rinsed and drained

1/4 cup thinly sliced red onion

3 cups baby arugula

Directions:

Combine oil, rind, juice, mustard, salt, and pepper in a large bowl, stirring with a whisk. Add beans and onion; toss well to coat. Add arugula; toss gently to combine.

This is a great vegetarian recipe that still provides some protein. Add some sunflower seeds, or a little cheese to amp up the protein content even further. 

Recipe Credit: http://www.cookinglight.com/recipes/lemony-white-bean-and-arugula-salad