WARNING – Explicit Medical Surgery Video

Video – Roux-en-Y (RnY) Gastric By-pass

WARNING – Explicit Medical Surgery Video

Video – Gastric Sleeve Bypass

VBS Pamphlet rev1109

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.

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It’s inevitable. Anyone who has lost a large amount of weight (more than 10-15 pounds) has hit one or more weight loss plateaus. The weight loss plateau is a very annoying period of body adjustment where your body “catches up with itself” so to speak. I hit two or three of them when I lost my 38 pounds and I learned a lot from each of them. I mostly learned patience!

There are two types of plateaus that occur. The first plateau is the short plateau, lasting two weeks to four weeks. The short plateau is the kind that all active “dieters” run into throughout their weight loss efforts. It is not necessary to make adjustments for this type of plateau, because your body is simply readjusting to your new weight. Over time (2-4 weeks) you will naturally start losing weight again, as long as you continue your healthy diet and exercise program. Patience is all you need to get past a short plateau.

The second type of plateau is the long-term plateau, which lasts for longer than four weeks. If you go for more than four weeks without losing weight, AND you are continually following a nutritious diet and exercise program (in short, you are doing everything perfectly), then you need to make some changes. A plateau lasting for longer than four weeks is because you are no longer asking your body to go beyond its point of comfort.

Let me explain this further. When you first start a new way of eating and a new exercise program, everything is a total shock to your body. All of a sudden you are filling the body with good, healthy good, full of nutrients, and you are pushing your body so it responds to physical activity. You burn a high number of calories because it requires a ton of effort just to do simple exercise. Over time, you adjust and become more efficient at exercise, and it no longer requires the same amount of calories that it once did. If you do not change your activity, and continue to eat the same amount of food, you will eventually stop losing weight. The same principle applies to food. If you cut your calories down to 1500 per day, and lost 15 pounds this way, your new weight may use those 1500 calories for maintenance now, rather than weight loss. It’s as simple as calories in = calories out.

So how do you break out of this long-term plateau? There are several things you can try, but the most important thing to remember is CHANGE. Any change is worth a try to shake things up a bit. Let’s start with food intake. Have you been taking in the same number of calories or fat grams since the beginning of your lifestyle change? If so, then you need to throw your body off, and there are a couple of ways to do this.

You can cut your calories or fat grams by a bit more (not a lot) to adjust for your new weight. You can try going off your healthy eating plan completely for 3-4 days. You can actually try increasing your calories or fat grams a bit per day. You can switch from eating three square meals per day to six smaller meals throughout the day. You can eat your largest meal in the morning and smaller meals at lunch and dinner. You can increase your water intake.

In the exercise department, you need to find ways to further challenge your body. You can try many different strategies. You can completely change your exercise method. If you only walked before, you can switch to cycling. You can introduce cross-training into your program. If you only walked before, alternate with cycling or aerobics. You can exercise for 5-10 minutes longer each day. You can exercise harder during your normal session time. You can introduce interval training, where you alternate intensity levels throughout your workout. You can add another day of exercise to your week. You can switch the time of day you exercise. You can start lifting weights. You can vary which activity you do first.

As you see, there are many different ways to try and break a plateau. I recommend that you start by trying two or three at the same time. If they don’t work, then next week try some others. It takes some experimenting to find out what will work for you, at this particular time in your weight loss journey. The steps I took to break my first plateau didn’t work to break my second, so be prepared to pull out something else from your arsenal. You can expect your new method will become effective within two weeks. If you are not seeing any results, then you need to change your method again.

If you are close to your goal weight (or ideal weight within reason) and none of these methods work, then you need to look at two factors. Have your body fat tested. It is very possible that you are already at your ideal body fat level and your body is not going to allow any further losses. Accept your new weight and congratulate yourself for the long, hard road you just traveled!

Long term weight loss and maintenance after Gastric Bypass

This info is sort of a “user’s manual” for the stomach pouch created in the Roux-en-Y Gastric Bypass. The guide is targeted to patients who underwent GBP more than 6 months previously, but the best results are achieved by patients who begin to live by these guidelines even before the procedure.

The first year after gastric bypass is usually very rewarding, but this time can also be confusing, frustrating and frightening. The function of the stomach pouch “tool” changes almost continuously over the first six months, and continues to change periodically over the year or so. Just when the patient feels they have begun to understand the stomach pouch/tool and how to use it, things change all over again.

There is an especially frightening change that takes place around 6-9 months after the surgery. The stomach pouch softens and expands slightly so that a patient regains a regular appetite and can “suddenly” tolerate a significantly larger amount of food. Patients frequently worry that something has pulled apart or broken on the inside, though this is rarely the case. This increased interest in food and increased capacity for food is a very natural and appropriate part of the recovery process after gastric bypass surgery. The reason it frightens patients so much is that they had previously felt they had control of their weight for the first time in their lives, and the renewed appetite threatens that they are losing control once again.

This page is about how to gain control of your weight using the stomach pouch “tool” and to keep control of the weight for life. The first thing to realize is that for the first six months or so after gastric bypass you did NOT have control of your weight. The pounds were going to come off almost no matter what you did. The stomach pouch could not handle enough calories to maintain weight for the first few months – we call this the “honeymoon” period after gastric bypass. The return of appetite and the increase in food capacity signal an end to the honeymoon period and a transition to the rest of life.

Your surgeon has created a stomach pouch that will be your tool to use to control your weight for life. We describe the stomach pouch as a tool so that patients understand the necessity that you learn how to use it, and stick with the “rules of the tool” over time. Patients who are aiming for the best long term success begin using these concepts and rules immediately after the gastric bypass. The time to really choose your new habits is during the early recovery after surgery – this is when your motivation is highest, and the rest of your life has been thrown out of kilter by the surgery anyway. Use this early recovery period to choose your new exerciseand diet habits. And even though patients lose weight “no matter what” for the first few months, use of the concepts outlined below will also maximize the weight loss during the honeymoon period – take advantage of this time so that when appetite and capacity return there is not so much further to go in achieving a weight goal.

The “Rules of the Tool”
OK, here are the magic “rules of the tool” (are you ready?): Diet and Exercise. Seriously. The good news is that diet and exercise, supported by your pouch/tool, can help you achieve your goal weight with excellent energy and without uncomfortable hunger. The specific guidelines are below:

Exercise keys
Regular exercise is at least as important to success as following the diet recommendations outlined below. In this context, regular exercise means some kind of vigorous aerobic activity, at least 45 minutes in duration, at least 5 days per week. Patients who achieve this goal can reliably expect to have improved energy and improved weight loss.

Hibernation mode and Hunting mode
It appears easiest to understand these benefits by thinking back to the evolution of our ancestors. Back in “cave man days” starvation was a constant threat, and our bodies were evolved to store any extra calories in preparation for the lean times. During lean times, the body is programmed to do everything possible to hold onto the calorie stores. So the first response of the body when faced with starvation (during a drought for our ancestors, or after gastric bypass surgery for us) is to conserve all possible energy by turning down the “metabolic thermostat.” This means that fewer calories are burned and the person feels like sleeping and being away from activity – they are easily fatigued. Some call this the “hibernation mode,” and it is as if the long winter has come and the best adaptation is to go way back into the cave and wait until the weather (and the hunting) improve. (Note that the hibernation response can also lead to depression and difficulty interacting with others.)

The role of exercise in this situation can be thought of as “fooling” the body into a different mode called “hunting mode.” If the body is treated to regular vigorous physical activity during starvation, its interpretation may be that the person is foraging or hunting. The body (from an evolutionary standpoint) would be in favor of hunting because it could lead to more calorie intake, so it provides more energy to facilitate the acquisition offood – it turns up the “metabolic thermostat”. This upregulation means that more calories are burned throughout the 24 hour period (besides the extra calories burned during the exercise) and the person has a significantly increased feeling of energy. Note that this discussion about hibernation mode and hunting mode is written as a way of understanding the observed effects of exercise after gastric bypass – these are not scientifically established physiologic events.

The best time to begin your exercise program is before the gastric bypass. Again we’re serious. Success in gastric bypass is all about choosing the right habits, with the support of the surgery to improve your success. If you exercise and diet before the surgery, you will have a strong impact on reducing your surgical risk. You will also benefit from having your plan in place, so you don’t have to figure it out during the confused recovery phase after surgery. If exercise is not begun before surgery, then it should be started as soon as possible after surgery. Discuss details with your surgeon, but generally we advise patients to maximize their physical activity from the outset.

This starts with walking on the same day as surgery, and should progress to more vigorous activity as the months go by. People who put off regular exercise until they feel “all recovered” or who try to start exercising when they realize they are not on course to reach their goal weight generally do not achieve or keep the new habit. Patients who work hard on exercise early after the surgery find it very rewarding. As the weight falls off, the capacity for exercise improves dramatically, with significant improvements on a week-by-week basis. Two objections to the exercise program that we frequently hear are that the patient is too heavy, or too fatigued. The first of these is unfortunately valid in many of our patients who are extremely heavy – people with a BMI of 70 or more frequently cannot engage in routine exercise. The good news is that people with extreme weights burn a large number of calories by simply walking. The amount of physical work done (which translates into calories burned) comes from how much mass is moved and how far it goes.

The message here is that the benefits of exercise can be realized in many ways – just work as hard as you can and do it frequently. Fatigue is the second objection. Patients sometimes tell us that they can’t imagine walking to the door and back, especially in the first few months after surgery. Our answer is to do your best to exercise anyway. This complaint is likely to be a manifestation of hibernation syndrome, which can be shaken off by exercise.

Diet Keys
The goals of the long term gastric bypass diet are:

* consume minimal calories (promote weight loss)
* consume adequate nutrition (achieve excellent long term health)
* achieve the two goals above without undue hunger or cravings

These goals can all be achieved by using the pouch/tool with the right kinds of food, at the right intervals, and with appropriate management of fluids. The first thing to understand is that when the pouch is filled with food it sends signals to the brain that say that hunger is satisfied – no additional food is needed. This feeling is called “satiety.” Any time a mature pouch is stretched by stuff inside it, the pouch will send a satiety signal to the brain, and (here’s the cool part) the satiety signal will continue as long as the stuff is still in the pouch! Therefore, keeping in mind the goals above, a patient should do the
following:

* Eat no more than three meals per day, with NO nibbling between meals. This will limit the volume of food and naturally limit the number of calories. One of these meals should definitely include breakfast – it has been shown that absence of nutrient intake causes the appetite center to “gear up” or become more sensitive, resulting in greater overall calorie intake through the day. This may work by means of an “ileal satiety feedback receptor” which (when exposed to nutrients several hours after they are taken in) may help suppress appetite. Use solid protein (chicken, fish, etc) as the basis for each meal. It is OK to use some vegetables for variety. The solid protein will meet your nutritional needs, and it is the best food to “hang around” in the pouch to give a longer feeling of satiety. Many patients learn early on that they cannot hold nearly as much chicken as they can mashed potatoes – this is a GOOD effect. The effect exists because solid proteins do not pass out of the pouch too easily, resulting in less volume consumed. Simple carbohydrates (potatoes, pasta, rice, bread) should also be minimized because of their effect on blood sugar. Simple carbohydrates are close relatives of sugar, so that the calories in these foods are rather easily absorbed and they tend to “rush” into the system and drive the blood sugar up quickly. Because the amount of carbohydrate consumed was not very large the blood sugar soon begins to fall, but by this time the pancreas is pumping out large amounts of insulin (a hormone which pushes blood sugar down) and this combination causes the blood sugar to drop too low. At this point the patient is experiencing hypoglycemia, and the deep urge to consume food – if they consume a simple carbohydrate (such as juice, or a bit of potato) they will be back on the blood sugar roller coaster. A cycle of blood sugar highs and lows such as this leads to consumption of way too many calories, and the calories have no nutritional benefit. On the other hand, proteins take a while to digest, and so they are absorbed slowly. This provides a longer term steadier energy source for your body, avoiding the high/crash cycle.
* Don’t drink liquids with meals, and don’t drink for at least two hours after your meal. Liquids taken after a meal will wash the food out of the pouch, releasing the tension on the walls of the pouch, and losing the feeling of satiety. In other words, consumption of liquids (with a mature pouch/tool) may be followed by a feeling of emptiness or hunger. Note that soup is a particularly poor food choice, because it is just like drinking with your meal. The liquefied food will pass quickly through the pouch, which allows more calories to be consumed and leaves the pouch empty. Note also that this part of the plan is not appropriate to begin practicing in the first three months or so after gastric bypass – in the early period after surgery it is enough of a struggle to get in adequate liquid (and hunger is not a huge challenge) that it is appropriate to begin drinking liquids about 30 minutes after you eat.

It’s a good idea to re-read this set of instructions each month until you’ve really “got it.” It takes a lot of effort, determination, and practice to use your pouch/tool in the best way – the good news is that the results are worth it!

Thanks go to Latham Flanagan, MD. Many of the concepts and many of the terms used in this outline have been learned from him. Dr. Flanagan practices bariatric surgery in Eugene, OR.

Understanding the function of the small gastric pouch

After surgery, it will be your responsibility for the lifestyle changes necessary to make the small gastric pouch function properly. It is thought that the pouch walls stretch with the eating of a small meal, or even the drinking of fluid. The meal volume will increase over the months. Stabilization occurs at two years, with a mean pouch size of six ounces, with a wide range of three to ten ounces. The pouch appears to not get larger after the second year. Success in weight loss and maintenance depends not only on having a small gastric pouch but even more so on how the patient makes the required lifestyle changes, uses their “pouch/tool”. and adequately exercises.

The accomplishment of satiety or suppression of hunger, is fundamental to the success or failure of bariatric operations. Almost all patients have a profound satiety, 24 hours per day, in the first six months following surgery. Patients achieve fifteen to twenty-five minutes of satiety after rapidly drinking water to a point of fullness. They do not redevelop a normal appetite preceding the next meal until 6 to 12 months post-op. Some patients fail their surgeries by staying too long on liquids or soft solids, the “soft calorie syndrome”. They fail by becoming hungry too soon before their next meal, and giving in to snacking between meals because of their hunger. High calorie drinks have the ability to defeat weight loss or maintenance.

The return of appetite occurs about six months. At this time, the average pouch size is four ounces. The patient can ordinarily drink six to eight ounces of water at a time.

The Ideal Meal Process

The ideal meal process is described as getting through the day without hunger on three meals a day. There needs to be about five hours between meals. The optimum meal is a more solid type of food, such as finely cut meat and minimally cooked or raw vegetables. The meal should be taken over five to fifteen minutes, depending upon the functional pouch volume. Stringing a meal out over 30 to 45 minutes is one technique used to “beat the pouch”. After 1-1/2 to 2 hours following a meal, begin drinking low or no-calorie fluids up to 15 minutes before the next meal. This use of fluids can substitute for taking in unwanted calories through snacking.

Finetuning of the pouch/tool is probably not accomplished until the patient redevelops hunger before the next meal, in the sixth to twelfth month after surgery. Techniques on delaying the return of hunger are not relevant when they are not hungry, as in the first six months.

Vomiting should be prevented if at all possible. For the first few months, a patient’s mouth will be larger than his stomach. The most common cause of vomiting is overloading the stomach. We encourage patients to continue to measure their meals. There are more complexities when eating foods such as rice, pasta and granola—foods that swell in the stomach after being eaten because they are incompletely rehydrated before being consumed.

Three Principles for Gaining and Maintaining Satiety

The golden opportunity for maximizing weight loss is the first six months after surgery. Two-thirds of the pouch growth occurs in the first six months. Every day the patient should take advantage of their present opportunity and get as active as they can.

Honeymoon Syndrome

The satiety and rapid weight loss due to intake restriction can lead patients to believe that circumstances will never change. This is the honeymoon period. Weight loss will slow. You may experience a false sense of comfort. Food selection, liquid calorie control and exercise are important.

Exercise

Exercise is critical for a healthy lifestyle. Exercise is necessary to maintain weight loss in the overweight person. The release of endorphins with aerobic exercise improves emotional stability and mental clarity. Endorphins, adrenalin, norepinephrine, etc., also act in an antidepressive manner. In the first six months, regular aerobic exercise improves basal metabolic rate that is observed to drop during rapid weight loss.

Long-Term Weight Management

Teeter-Totter Effect

On one end is the exercise/phyiscal activities. On the other end is the meal choice discipline and fluid restrictions.

Too Much Weight Loss

Up to 15% of patients can lose too much weight in the first and second year post-op. We encourage them to taper off their efforts with diet discipline by adding some fat back to their meals and eating and fourth or fifth meal a day with less discipline on the fluid management.

Depression

Depression is a powerful inhibiter of success after surgery. Patients have reversed the learned principles of the use of their pouch/tool: grazing and snacking through the day, drinking high calorie liquids, drinking liquids with meals, and stopping their exercise. Consider professional counseling, as needed and continue to use your pouch/tool as best you can. Consider a “refresher” course” in the use of the principles of the pouch/tool at some time in the future.

Adapted from: Understanding the Function of the Small Gastric Pouch: Application to Post-op Teaching and Evaluation, by Latham Flanagan, Jr., M.D., FACS

Post Gastric Bypass Dietary Guidelines:

For the first two weeks after surgery, you will progress from a liquid diet (i.e. soups, unsweetened juices and skim milk) to small amounts of blenderized foods. After two weeks, you will progress to soft, well-cooked, chopped or minced foods. Finally, you will advance to small amounts of solid foods, with emphasis on healthy food choices.

Gastric Bypass Diet – Stage 1 (First Two Weeks)