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Pasadena, CA 91105

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Pre-Operative Work-Up

March 19, 2016 11:14 pm

Prior to any surgery that involves general anesthesia, a number of diagnostic tests need to be performed. Weight loss surgical procedures are no exception. In fact in most cases a more in-depth and extensive pre-operative evaluation is needed prior to weight loss surgery.

Pre-operative patients will be required to have an EKG, chest x-ray and complete blood work prior to the surgery. The blood work will include a comprehensive evaluation of the patient’s nutritional status by measuring vitamin and mineral levels. Some patient’s may require upper endoscopy and/or upper GI series prior to their surgery to evaluate their anatomy. Based on the patient’s past medical history, some may be required to have a sleep study, while others may require a complete cardiac evaluation.

Our office will coordinate and help you complete the preoperative workup. We have also composed a document to help each patient optimize their pre-opertiave health care status here.

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Financing and Cash Options

March 19, 2016 10:40 pm

Insurance benefits can be complicated and difficult to obtain for weight-loss surgical procedures. Investing in your health and yourself can still be an option through financing or cash options. We offer competitive cash options for weight loss surgery. Please contact our office, either by phone 818-812-7222 or our online form, for information regarding cash options.

For those traveling from out of the local area, please see our dedicated Travel Information page and map of patients who have traveled.

Cash Option

Paying out of pocket for your weight loss surgery can be a very stressful process, but we make it as easy as possible for you.

In order to make the process easier, we will assist you throughout the process. Pricing for each procedure depends on many variables, health status and history. Our staff will walk you through all of the costs associated with the procedure that best suits your needs and health status. We are confident that when you compare our costs and benefits with those of other providers you will agree that Dr. Ara Keshishian and Central Valley Bariatric offers a great value and comprehensive program.

Keep in mind that the price of our procedures includes the following:

  • Pre-Operative Consultation
  • Post-Operative Appointment
  • Facility Fees
  • Surgeon Fees
  • Anesthesia Fees
  • IV Therapy
  • Member Exclusive Information and Blogs

Additional cost, not covered are:

  • Pre-Operative labs, EKG and surgical clearance*
  • Post-Operative prescription medications
  • Protein Shakes and Vitamins
  • Airfare
  • Hotel & Transportation
    * Pre-Operative labs, EKG, and surgical clearance are necessary prior to your arrival to ensure you are healthy enough for surgery! This is usually covered by your medical insurance.

Prices vary according to surgery performed and payment method. Please schedule a consultation to find out your exact pricing. The weight loss surgical procedures that we offer are:

  • Duodenal Switch
  • Revision to Gastric Bypass to Duodenal Switch
  • Revision to other Weight Loss Surgeries
  • Sleeve Gastrectomy
  • Revision of Sleeve Gastrectomy to Duodenal Switch
  • Other options

Please keep in mind that the cost of surgery can be tax-deductible. The IRS does allow the deduction of weight loss programs, including surgery when medically necessary. Follow this link for more information: https://www.irs.gov/publications/p502/ar02.html (click on weight loss programs). Note that the cost of surgery must exceed 7.5% of your adjusted income. Other costs designated by the IRS, including weight loss surgery prep programs, health insurance premiums, postoperative visits, smoking cessation programs, and other delineated costs, may help you meet this requirement. Please consult with your accountant for further details.

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Revisional Weight Loss Surgery*

March 19, 2016 8:27 pm

revision-ad-3

Each weight loss surgical procedure has a different short and long-term result, as well as unique and long-term complications. Patients who have had complications or ill effects as a result of weight loss surgery may require other procedures to correct the original operation. These types of operations are called revisional weight loss surgical procedures. In the last 18 years, Dr. Ara Keshishian has performed more than 500 revisions from other Weight Loss Surgeries such as RNY Gastric Bypass, Adjustable Gastric Band, and Sleeve Gastrectomy to Duodenal Switch on patients who have come from all over the United States and other countries. He first published his data on Revisional Weight Loss Surgery in 2004.

 

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Conditions that may require Revisional Weight Loss Surgery include:

  • Inadequate weight loss.
  • Weight regain after initial weight loss.
  • Dumping syndrome.
  • Solid intolerance.
  • Marginal ulcers.
  • Nutritional deficiencies, including vitamins, minerals, etc.
  • Anemia.
  • Significant bowel dysfunction (constipation, diarrhea, malodors flatulence).
  • Significant gastroesophageal reflux disease.
  • Infection involving implanted devices (ports or bands).
  • Erosion or slippage of the adjustable band.
  • Partial resolution of the comorbid conditions or recurrence of the comorbid conditions after initial or partial resolution.
  • Stricture (narrowing at the site of bowel anastomosis).

Animation of Revision of Gastric Bypass to Duodenal Switch

The goal of the revisional weight loss surgery is to:

  • Correct the problem that brings a patient under our care, including the correction of any of the above outlined conditions.
  • Make the revisional weight loss surgery a definitive procedure. This will be discussed further with each type of procedure that we revise.
  • Accomplish the primary goal of the weight loss surgical procedure, which is maintenance of the weight in a favorable range and resolution of the patient’s comorbid conditions.
  • Revisional Weight Loss sSurgery should have acceptable risk as a surgical intervention.

The majority of patients seeking a revisional weight loss surgery are those who experienced an acceptable short-term outcome after the initial weight loss surgical procedure. They may have lost the weight only to gain it back, or experienced inadequate weight loss. There are also certain patients who have had ill effects from their primary operations, including ulceration and stricture in the case of a Roux-en-Y gastric bypass, and slippage or erosion in the case of an adjustable gastric banding. While there are some patients who have been able to lose the weight and keep it off, this comes at the expense of near constant nausea and frequent episodes of vomiting. It has been our experience that the failure of primary weight loss surgical procedures is quite frequently blamed on the patient, which is usually not the case. In the majority of cases, a less than ideal outcome of a weight loss surgical procedure can be traced back to a procedure itself. A similar circumstance would involve a patient trying a number of blood pressure medications to find the one that works best. Even the best possible outcome may be inadequate for the patient and his or her particular conditions.

The causes of failure of primary weight loss surgical procedures may be:

Cause
  • Dilated pouch stoma
  • Fistula (gastro-gastric, gastro-enteric)
  • Marginal ulcer
  • Significant nutritional deficiency including iron deficiency anemia
  • Stricture
  • Excessive diarrhea or debilitating malodorous flatus
  • Significant protein calorie malnutrition
  • Gastric bypass revisions are indicated for any of the above conditions
  • Significant nutritional deficiency including iron deficiency anemia
  • Excessive diarrhea or debilitating malodorous flatus
  • Significant protein calorie malnutrition
  • Slipped Band
  • Erosion of the Band
  • Port problem including flipped port or infection
  • Inadequate weight loss
  • Incomplete resolution of co-morbidities
  • Revision of a lap band may be indicated for any of the above conditions

Each one of the surgical procedures will be discussed in great length with the rationale for the recommended revisional weight loss procedure.

Sleeve Gastrectomy

The popularity of Sleeve Gastrectomy has increased the number of people who have had this procedure. However, in certain circumstances the weight loss might be inadequate or a person might experience regain following Sleeve Gastrectomy. The procedure for converting a Sleeve Gastrectomy to Duodenal Switch can be achieved to maximize weight loss and/or regain.

Roux-en-Y, Gastric Bypass

Roux-en-Y Gastric Bypass is a procedure in which a small stomach pouch is created and connected to a limb of small bowel in which a deliberately small opening is made. The purpose of the small pouch and the small opening is to restrict the amount of food that a patient can eat in any given setting and to purposefully delay the emptying of the pouch to give the patient a longer period of feeling full.

Complications of the Roux-en-Y gastric bypass include dumping syndrome, marginal ulcer, cases of persistent nausea and vomiting with solid intolerance, inadequate weight loss, and weight regain. In our opinion, the best option for cases of Roux-en-Y gastric bypass in need of revision is the Duodenal Switch operation. Adjustable gastric banding (Lap Band) placement as a revisional weight loss surgery for a primary Roux-en-Y may only be considered for patients who have experienced an initial success of weight loss followed by weight regain. This should, however, only be used for those not experiencing dumping syndrome, marginal ulcer, or reflux disease, as it can potentially get exacerbated by placement of the band on top of a gastric pouch.

Adjusting the length of the common channel, or alimentary limb, allows a revisional weight loss surgery to be tailored to the patient’s needs. An example would be if a patient is experiencing persistent nausea and vomiting and seeks the revision of a failed gastric bypass to a Duodenal Switch. If a patient seeks the revision of Roux-en-Y for persistent nausea and vomiting while experiencing adequate weight loss, a relatively long common channel and alimentary limb (percentage based) will be set for the patient, thus preventing any further weight loss while correcting the persistent nausea and vomiting problem.

In contrast, a patient seeking the revision of a failed gastric bypass to a Duodenal Switch due to inadequate weight loss and/or weight gain will have a relatively shorter common alimentary channel (percentage based) in order to maximize the amount of weight loss. In our opinion, revising a failed gastric bypass, from a proximal to a distal Roux-en-Y, is an extremely poor choice in the majority of the patients, as the distal gastric bypass has the worst nutritional safety profile of all the known surgical procedures.

Adjustable Gastric Banding
Lap Band, Realize

Adjustable gastric banding is a restrictive procedure in which a very small pouch of the stomach is created and partitioned solely by the placement of a ring that can be adjusted by the addition or removal of sterile saline through a port.

In the majority of cases, the reason for inadequate weight loss may be related to inadequate adjustments or unrealistic patient expectations in regard to the anticipated weight loss. All of the published reports to date identify the amount of weight loss to be approximately 50% of the excess body weight, and patients that have a large amount of weight to lose may never attain adequate weight loss to resolve their comorbid conditions.* This may be an example of patients having attained the weight as expected by the surgery, yet experiencing a less than ideal weight loss surgical procedure for their general health condition to include their excess weight and their comorbid conditions. The majority of the patients that had adjustable gastric banding being inadequate weight loss or significant reflux disease in the presence or absence of hiatal hernia. It is our recommendation to have this procedure conversed to Duodenal Switch.

Duodenal Switch

Duodenal Switch operation is the primary weight loss surgical procedure that we perform. It is a hybrid operation in which a banana-shaped stomach is created. Additionally, two parallel limbs of small bowel are created to carry down the ingested food separately from juices from the liver and pancreas. No small bowel is removed. This limits the amount of absorption of calories and nutrition thus magnifying the amount of weight loss.

The most common reason for revision or reversal of the Duodenal Switch operation in our experience has been 1) inadequate weight loss, and a distant second) significant diarrhea. In the case of inadequate weight loss, greater than 80% of the patients in our experience have had dilated stomach which has rendered itself easily to a re-gastrectomy with excellent results. Very few patients have benefited from shortening of the common channel.

The revision/reversal of the Duodenal Switch operation for significant amounts of loose bowel movements and malodorous flatus is easily accomplished by creation of a side-by-side anastomosis.

In fact having extensive experience with revision of weight loss surgical procedures it is our opinion that from a technical perspective, revision or reversal of Duodenal Switch operation is technically the safest and easiest of all the other surgical procedures.

*https://www.dsfacts.com/pdf/agb-long-term-results-1506834076.pdf

Are you a candidate for Revisional Weight Loss Surgery? Contact our office here.

Category :

Enhanced Cognitive Function after Bariatric Surgery

March 18, 2016 6:51 am

The adverse effects of obesity reduce the body’s natural potential of optimal physical, mental health and cognitive function. Obesity is associated with a greater risk of health problems such as hypertension, stroke, diabetes, and sleep apnea. These issues attribute to an increased risk of dementia and cognitive dysfunction.

Glucose homeostasis plays a key role in the neural mechanisms of the brain. Insulin signals nutrients by circulating within the body in proportion to body fat mass. In addition to other regulatory mechanisms, this allows the brain to control feeding behavior by stimulating energy storage and metabolic homeostasis. Metabolic imbalances modify insulin sensitivity and lead to impaired glucose output inhibition [Qatanani and Lazar et al., 2007 (1)].

System effects of free radicals
System effects of free radicals

Free radicals are formed when weak molecular bonds are split. Their instability causes them to attack neighboring stable molecules and lead to a chain reaction of disturbing living cells. Antioxidants, such as vitamins C and E, defend the body from the damaging effects of free radicals by acting like scavengers. They protect cells from tissue damage that can potentially lead to disease.

Moreover, insulin resistance links oxidative stress, which is the continuous imbalance between free radical production and the body’s antioxidant defenses to detoxify its harmful effects. Enhanced oxidative stress is a result of accumulated fat, which impairs the secretion of insulin and damages glucose uptake in muscle and fat. Increased oxidative stress is the underlying cause of pathogenesis in vascular cell walls that lead to the development of cardiovascular problems, plaque formation. Data suggests, in a study conducted by Dr. Convit (2) in 2002, that management of blood sugar levels may enhance memory and possibly decrease the risk of Alzheimer’s disease.

In congruence with these findings, added stress due to excess weight can negatively affect the anatomy and physiology of the body. A study in 2010, led by Dr. Thompson (3), concluded that obesity is associated with “atrophy in brain areas targeted by neurodegeneration: hippocampus, frontal lobes, and thalamus” [Raji et al., 2010 (3)]. These brain regions play a critical role in the maintenance of memory, executive function, and sensory interpretation, respectively.

Central respiratory function is also disrupted by the mechanical effects of obesity. Reduced lung expansion is especially destructive during sleep. Obstructive sleep apnea is a disorder where breathing stops for brief periods because of an obstructed upper airway. Excess weight and increasing body mass index (BMI) restricts expansion of the chest wall and increases airway resistance, which decreases lung volume [Zammit et al. 2010 (4)]. This boosts respiratory muscle workload for consistent breathing. Complications of sleep apnea include fatigue, heart problems, metabolic syndrome, and more.

Cognitive impairments lead to deficits in executive function, response, reflex time, planning, and memory [Spitznagel et al. 2013 (5)]. Blood sugar levels, oxidative state, respiration and other mechanisms influence our cognitive abilities. Weight loss from bariatric surgery may reduce the comorbidities of an obese patient. The primary outcomes are improvements with diabetes, blood pressure, glucose levels, sleep apnea, BMI, and excess weight resolutions.

Schematic of how cognition is effected by obesity. Source (1)
Schematic of how cognition is effected by obesity. Source (1)

Weight loss surgery reverses the stressors of the body to permit the development and preservation of cognitive function. By improving anatomical aspects of physical health, the overall mental well-being of patients is remarkably enhanced.

A number of studies have looked at the short [Gunstad 2011(6)] and intermediate  [Alosco 2013, (7)] term improvement in memory function after weight loss surgery

Thank you to Contributor: Mariam Michelle Gyulnazaryan

References for Cognitive Function

  1. Qatanani M, Lazar MA. Mechanisms of obesity-associated insulin resistance. Genes & Dev. 2007; 21: 1443-1455.
  2. Convit A, Wolf OT, Tarshish C, de Leon MJ. Reduced glucose tolerance is associated with poor memory performance and hippocampal atrophy among normal elderly. PNAS. 2013; 100 (4): 2019-2022.
  3. Raji CA, Ho AJ, Parikshak N, Becker JT, Lopez OL, Kuller LH, Hua X, Leow AD, Toga AW, Thompson PM. Brain structure and obesity. Hum Brain Mapp. 2010; 31(3): 353-364.
  4. Zammit C, Liddicoat H, Moonsie I, Makker H. Obesity and respiratory diseases. Int J Gen Med. 2010; 3:335-343.
  5. Spitznagel MG, Alosco M, Strain G, Devlin M, Cohen R, Paul R, Crosby RD, Mitchell JE, Gunstad J., Cognitive function predicts 24-month weight loss success following bariatric surgery. Surg Obes Relat Dis. 2013; 9(5): 765-770.
  6. John Gunstad, Gladys Strain, Michael J. Devlin, Rena Wing, Ronald A. Cohen, Robert H. Paul, Ross D. Crosby, James E. Mitchell, 2011, ‘Improved memory function 12 weeks after bariatric surgery’, Surgery for Obesity and Related Diseases, vol. 7, no. 4, pp. 465-472
  7. Michael L. Alosco, Mary Beth Spitznagel, Gladys Strain, Michael Devlin, Ronald Cohen, Robert Paul, Ross D. Crosby, James E. Mitchell, John Gunstad, 2013, ‘Improved memory function two years after bariatric surgery’, Obesity, vol. 22, no. 1, pp. 32-38
  8. Furukawa S, Fujita T, Shimabukuro M, Iwaki M, Yamada Y, Nakajima Y, Nakayama O, Makishima M, Matsuda M, Shimomura I. Increased oxidative stress in obesity and its impact on metabolic syndrome. J Clin Invest. 2004; 114(12): 1752-1761.
  9. Mitchell JE, de Zwaan M. Psychosocial assessment and treatment of bariatric surgery patients. 2011;6: 103-109.
  10. Nguyen JCD, Killcross AS, Jenkins TA. Obesity and cognitive decline: role of inflammation and vascular changes. Front Neurosci. 2014; 8: 375.
  11. Chan JSY, Yan JH, Payne VG. The impact of obesity and exercise on cognitive aging. Front Aging Neurosci. 2013; 5: 97.

Acanthosis Nigricans

November 16, 2015 9:28 am

There are a a number of skin conditions that are associated with the disease of obesity. Acanthosis Nigricans is characterized as areas of thickened, dark, velvety discoloration in body folds and creases. Usually seen in the armpits, neck, under the breasts, in the skin folds of the abdomen and groin. The exact cause of it at the molecular level is not clear other than seen frequently with insulin excess in the case of benign conditions. This symptom can give a warning about health conditions that require further investigation.

Patients may assume excessive sweating and poor hygiene are the causes of this condition- both of which are incorrect.

Screen Shot 2015-11-15 at 8.36.13 PM

Acanthuses Nigerians is caused by acanthosis and papillomatosis of the epidermis (the outer most layer of the skin)  pigmentation is usually not in this area,  rather than pigment-producing cells. The skin proliferation abnormalities in acanthosis nigrcans are frequently associated with hyperinsulinemia and insulin resistance. This probably presents the best understanding of the pathology behind it. It suggests that the layer of  skin gets thicker probably caused by some stimuli- as indicated above seen with insulin excess.

There are two forms of this condition: Benign and Malignant.

Benign forms are associated with obesity, insulin resistance, and type II diabetes.

Insulin resistance: Insulin is a hormone secreted by the pancreas that allows your body to process sugar. Resistance predisposes to type II diabetes.

Hormonal disorders: Hypothyroidism, Polycystic Ovarian Disease, and other endocrine disorders of adrenal glands are ovaries

Drugs: Certain drugs and supplements such as high-dose niacin, birth control pills, steroids, may cause acanthosis nigricans.

Malignant forms may be an indication of Gastro-intestinal cancer such as stomach, colon, or liver cancer.

Treatment: No specific treatment is available for acanthosis nigricans. Treating the underlying conditions may restore some of the normal color and texture to affected areas of skin.

2015 ASMBS Summary

November 11, 2015 7:31 am

The 2015 ASMBS meeting was held November 2-6, 2015.  It was combined with TOS (The Obesity Society) and had more than 5,600 attendees from all over the world in every aspect of obesity treatment.  There were some interesting additions and deletions from this meeting compared to the past.

The one sentence that comes to my mind is “I told you so”.

One important addition was a DS course for Surgeons and Allied Health.  This was very exciting, except the content and questions seemed to gravitate to  SADI/SIPS/Loop rather than DS.  Dr. Cottam was one of the moderators of the course.  It seems that they have found the value in preserving the pyloric valve. It was clear that the discussion was driven by the need to come legitimize the single anastomosis procedures at this early stage with almost no data to prove long term outcome. With many of the Vertical Sleeve Gastrectomies having re-gain and the they are looking for a surgery that the “masses” can perform. This was actually the term used by one of the presenters, implying that the duodenal switch needed to be simplified so that all surgeons, those who have pushed all other procedures can not offer Duodenal Switch to their patients with less than desirable outcome.   Several surgeons also voiced their concern and dissatisfaction with the issues and complication of the RNY and want an alternative.  There was much discussion regarding SADI/SIPS/Loop being investigational and that it shouldn’t be as it is a Sleeve Gastrectomy with a Billroth II.  Dr. Roslin and Dr. Cottam discussed their SIPS nomenclature saying they wanted to stay away from something that had Ileostomy, suggesting bowel issues, or the word “SAD”i  due to negative connotations. The point to be made is that the SADI and SIPS and the loop are all the same.  I have also noticed other surgeons using SADS (Single Anastomosis Duodenal Switch).  There is a great deal of industry behind these procedures and many surgeons being trained in courses funded by industry. One surgeon stood up and informed the entire course that they need to be clear with their patients about the surgery they are performing, as he had been in Bariatric chat rooms and there is upset within the community about SADI/SIPS/Loop being toted as “the same or similar to Duodenal Switch”.

There was also presenter who said “We are doing something new about every five years.” No,  “we” are not. Some of us have stood by the surgery and techniques with the best long term outcomes and not gone with every “new” thing out there. The process of  Duodenal Switch may have changes, open Vs. Lap, drains, location of incisions, post operative care and stay, but the tested procedure with the best outcome has been the duodenal switch operation and not the shortcut versions. Although, those of us that are standing by long term results seems to be in the minority. Why do I stand by Duodenal Switch?  Because it works, when done correctly by making the length of the bowel proportional to the patient total bowel length, and height, and not just cookie cutter length for all patients,  with the right follow-up, patient education, vitamin and mineral regime and eating habits.

A new addition was the Gastric Balloon, which in the research presented had a 60-70% re-gain rate and a no more than 10-15% weight loss one year only. This data represents more than 70% weight regain when the balloon is taken out.  The Gastric Balloons can be left in between 4-6 months depending on the brand or type of balloon. The Gastric Balloon is not new to the Bariatrics and was first introduced in 1985. After 20 years and 3,608 patients the results were  and average of 17.6% excess weight loss. It seems that we are re-gurgiating old procedures. There are many new medications that were front and center in this meeting.

The Adjustable Gastric Bands were missing from the exhibit hall this year. It is my hope and feeling from the other attendees that we may be seeing the era of the Adjustable Gastric Band being placed in patients come to an end.  Although there are some still holding out that there are some patients that can do well with the Band.

Attending the 2015 ASMBS meeting this year, as it has every year, only reemphasized the importance of avoiding what has become the norm of chasing a simple solution that is fashionable and easy now. We stay convinced that the duodenal switch operation with the common channel and the alimentary length measured as a percentage of the total length is by far the best procedure with the proven track record. The patient should avoid the temptation of settling for an unproven procedure or device, because if history holds true, there will be a need for revision surgeries in the future.

 

 

 

 

Bowel Length in Duodenal Switch

November 09, 2015 6:25 am

Malnutrition is one of the most feared complication of the duodenal switch operation. It may present years after surgery. What is common is a mix of nutritional deficiencies which include fat soluble vitamins, and protein calorie malnutrition. These all point to possible excessive shortening of the common channel. In my practice we have seen patients that have had lengthening of their common channel to improve their metabolic picture. What is very obvious to us, is that we see disproportionately higher number of cases coming to us for revision from practices where the common and alimentary lengths are done as a “standard” numbers with no specific adjustments made for the patient, their anatomy and situation. I have said for years, that the length of the bowel that is measured to be become the common and the alimentary limb should be a percentage of the total length of small bowel, rather than a pre-determined measurement. Here is a visual description of how this works.

If a common channel and the alimentary limb is measured to be a percent of the total length then the chance of protein calorie malnutrition is minimized since this will take into account the bowels absorptive capacity which is being reduced. This decrease in the absorption is done as a fraction of the total length.

Raines et al. published  a study in 2014, that showed how small bowel length is related more closely to a patient’s height and not weight.  And yet, some surgeons totally based the length of the common channel and the alimentary limb arbitrarily based on the patient pre operative BMI and nothing else. Could this be the cause of why I see some patients coming to us for revision of their duodenal switch for malnutrition?

Staying on Track and Surviving Halloween

October 27, 2015 6:07 am

happy-halloween-clipart_3

Halloween is the start of  temptations during the holiday season and surviving Halloween is possible. It’s a time of high carbohydrate treats that can turn into a nasty trick of regain or slowed weight loss. Halloween is a fun holiday that you can participate in with some foresight and planning.  Sugar and simple carbohydrates are easily absorbed and can decrease weight loss or regain. The following are some helpful tips to keep you on track.

  • Stay steady with high protein, hydration, vitamins and minerals.  Protein and hydration will keep you full and help curb the carb cravings.
  • Make you own high protein treats.  There are so many great recipes out there.
  • If you give out candy don’t buy candy that you like.  In fact, do the opposite and buy candy you dislike.
  • Don’t give out candy at all. Instead opt to do a non-candy type item, stickers, pencils, rings, trinkets, easers, small coloring books, or other small items.
  • Keep a list of your goals posted in a visible place.
  • Make a picture collage of your goals, achievements you want, and non-scale victories you’d like to achieve posted in a high visibility location.

Stay strong and avoid the pitfalls of temptation.