Coping Skills after Bariatric Surgery
June 02, 2015 7:23 am
For many people, food can become a coping mechanism and a way to self sooth or comfort themselves. After weight loss surgery the ability to use food in this manner is disrupted due to the smaller portions and in some cases food intolerances. Developing alternative and healthy coping skills is an imperative step after weigh loss surgery.
Obesity is a multifactorial process that has many contributing aspects. Although, obesity is not entirely the result of poor eating behavior, and lack of exercise. After weight loss surgery, we should appreciate the importance of healthy dietary choices; being sure that volume and frequency is not driven by emotion or emotional eating.
The mental aspect of weight loss surgery should not be ignored. Developing healthy coping skills can be a large part of dealing with the changes that take place. Some people go through a mourning period for the loss of the foods that once gave them comfort, made them part of a group, or the feeling of their best friend. In some cases, there may be a need to seek the assistance of a mental health care provider to be able to work through some of the issues and feelings. Never hesitate or be afraid of contact a mental health care professional.
Learning and practicing effective coping/soothing techniques can be started prior to weight loss surgery. The following are some coping skills that can be effective for some to adopt into their daily lives.
1. Nature – Get out into the great outdoors and into the sunlight. The sounds and sights of nature have a way of energizing the body and calming the mind. Sunlight is excellent for increasing Vitamin D levels which can help elevate mood and general well being.
2. Exercise – The mental and physical effects of exercise are paramount after weight loss surgery. The natural chemical release from exercise is a calming effect and gives a sense of well-being. In addition, the physical aspects of increase weight loss and change in body contour have positive mental and emotional effects.
3. Music- There are many research articles regarding the positive effects on both metal and physical aspects of music. Music has a way of soothing or energizing the soul. Turn up loud or keep it soft. Sing along. Dance it out if you need to.
4. Journaling – We always suggest to people prior to weight loss surgery to start journaling. It can give you perspective when you look back at entries. We also suggest to journal body measurements, pictures, and weights so that you might look back at how far you’ve come from your starting point.
5. Mindfulness – Using all five sense to experience life and food. Take your time to take everything in and experience the full effect. Be present in all life experiences. Ask yourself: Am I enjoying this? Does this feel like what I need? Is this getting me to where I want to be? Is this healthy for me?
6. Support groups of peers- There is nothing like having a group of people who have been there or know exactly how you may be feeling to be able to talk, share or vent. There are so many support groups that can be taken advantage of in either face to face or cyber groups.
7. Treat yourself- Treat yourself and practice self-care by doing something that you find relaxing, gratifying or energizing. Massage, manicure, an outfit, shoes, an outing, or a class.
8. Distraction- Hobbies, new skills, reading, games, bubble bath, or anything that get you out of the same mental spot can help with calming and soothing.
9. Talking- There is great value in having a close friend or trusted therapist to be a sounding board and give you an opportunity to unload some of the challenges you’ve been carrying.
Changing habits and coping skills takes practice and patience. It is not something that is easily changed over night. Focus on small steps, goals and achievements. Give yourself time and credit for the accomplishments that you’ve made. Always look at how far you have come and the positive lifestyle changes you’ve made. There may be set backs but don’t beat yourself up about it, move on and continue to take steps toward your goal.
https://www.counselorlady.com
Aetna and Blue Shield 6 month Diet Requirement Changes
May 15, 2015 3:16 pm
- Member’s participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member’s participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Records must document compliance with the program; the member must not have a net gain in weight during the program. Note: A physician’s summary letter is not sufficient documentation. Documentation should include medical records of physician’s contemporaneous assessment of patient’s progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member’s participation and progress may substitute for physician medical records; and
- Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote); and
- Nutrition and exercise program(s) must be for a cumulative total of 6 months (180 days) or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least 3 consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of 6 months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.)
Shared Success Story- Dr. D. Brown
April 13, 2015 11:38 am
I had Roux-en-Y (RNY) gastric bypass surgery in February 2004. I was told it was the “Gold Standard” procedure and it was the only one my insurance would approve (according to the surgeon’s office). I lost around 130 pounds with some minor bounce back. Kept it off for 7 years. I had so much energy; I decided to go back to school to become a doctor.
In medical school I really began to regain, for a total of 75 pounds over 5 years. I tracked food and found that if I ate more than 1300-1400 calories daily, I was gaining. I had absolutely no sugar dumping or satiety or restrictive effects left from the RNY Gastric Bypass, only my metabolism’s memory of starvation mode.
In fact, I never had one incident of dumping syndrome; I only felt satiety for the first 2 years and was able to eat well over 2 cups of food per meal by year 7. Lack of dedicated exercise, extreme stress (time, financial & academic) as well as poor food choices all contributed to my regain. However, the RNY Gastric Bypass surgery only has an average long-term excess weight loss of around 50%, so that still makes my weight regain close to the acceptable range.
Finally, I looked into revision surgery. Not only is surgery always a major decision, but also a revision to a DS is a very technically complicated surgery. I extensively researched all the options to make the right decision. The Duodenal Switch surgery has the best long-term statistics for maintained weight loss in all the medical studies (close to 75% excess weight). The major feature is nutrient malabsorption. The amount is dependent on an individual basis but most fat and some protein calories are not absorbed. There is an initial restrictive component as well. With the nutrient malabsorption also comes vitamin/mineral malabsorption. However, RNY also causes vitamin malabsorption and I was already taking vitamins, so what’s a few more? I am just 4 weeks post-op now and am still in trial-&-error mode, but I have found a safe plan for returning back to work. I really could not have afforded any complications and am so glad that I placed my trust in Dr. Keshishian.
Dr. D. Brown
Starting wt: 274.0
Vitals for 4-16-15 (4 weeks post DS)
wt = 249.0
T = 97.7
P = 88
BP = 108/80
Weight loss Surgery Coverage Changes
January 20, 2015 10:30 pm
Weight loss surgical procedures have been proven to be the only viable option for sustained weight loss when compared to all other modalities, including diet, exercise, behaviors modifications, appetite suppressant, and other less scientific approaches. Different weight loss procedures have had varying degree of success as measured with resolution of the co-morbidities and long term weight loss.
One such specific modification in policy involves primary and revision weight loss surgery.
These policy changes have significant practical implications for those seeking surgical treatment for morbid obesity and associated co-morbidities.
First of all, they create a road block for those patients who are not able to provide documentation for the “…6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance.” It also places the responsibility on the surgeon by requiring that compliance with these requiremens are “…. fully appraised and documented by the physician requesting authorization for surgery.”
For all those who are not in California, please note that a lot of policies do start here and propagate to the rest of the country. I would propose that everyone take time to contact their state health insurance providers regulatory agency and voice their opposition to the proposed changes.
The state regulatory agencies are located here. (https://www.dsfacts.com/image-files-new/agencies-by-state.pdf)
2015 Back on Track or A New Start after Weight Loss SurgeryExclusive Member Content
January 08, 2015 8:37 pm
Holiday Survival Tips by: Marylin Calzadilla, Psy.D.
November 17, 2014 8:23 pm
REFLECT
SUPPORT, SUPPORT, SUPPORT
ALLOWANCES
KEEP ACTIVE
CREATE
PLAN ACTIVITES
Marylin Calzadilla, Psy.D
Optimizing Pre-operative Health Status
November 12, 2014 1:23 pm
- Maintaining a healthy diet
- Cessation of ALL tobacco and alcohol use
- Do not use NSAIDS prior to surgery or after surgery until cleared by surgeon
- Getting plenty of rest
- Staying Hydrated
- Pulmonary embolus prevention exercises such as ankle circles and point and flex toes
- Maintaining or starting a regular activity level. Any amount of increase in activity will benefit you after surgery. Walking, squats, lifting weights with arms
- Full laboratory blood studies and vitamin levels as ordered by the surgeon
- Start and optimize your vitamins, calcium and other mineral and supplements. Vitamin D deficiency increases surgical complications. (Another Vitamin D article)
- Manage preexisting health conditions (diabetes, sleep apnea, high blood pressure etc..) Follow instruction in regards to what medication to stop or continue before surgery i.e. Aspirin, blood thinners, medications that interfere/interact with anesthesia, etc.
- Two forms of Birth Control if indicated.
Mental preparation:
- Have a clear understanding of the procedure
- Study all information provided to you regarding your surgery
- Remember that surgery is one of many tools to assist in weight loss and improved health. It does not fix other issues.
- Realistic expectation of the outcome of surgery
- The role of family involvement for support
- Be prepared with all the purchases for the post operative diet, vitamin and mineral supplements.
- There is also a number of other variables that will improve the long term outcome of the weight loss surgery:
- Investigate Protein Supplements for the highest bioavailability
- Try and eat whole, unprocessed foods
- Read labels on all food items
- Look for high protein recipes
- Network with supportive people who will provide a positive influence
- Long term success also depends on:
- Maintain daily protein requirements
- Maintain daily vitamins, calcium, minerals and other supplements
- Routine follow up with your bariatric surgeon.
- Routine laboratory studies to surveil vitamin and mineral levels.
- Get your medical advice from your surgeon.
- Get suggestions from other patients. Do not confuse this with medical advice.
Telogen Effluvium: Hair Loss After WLS (Weight Loss Surgery)
September 14, 2014 12:56 pm
Telogen Effluvium is the premature pushing of the hair root into a resting state and can be chronic or acute. It is usually brought on by a shock to your body such as high fevers, childbirth, severe infections, severe chronic illness, severe psychological stress, major surgery or illnesses, over or under active thyroid gland, crash diets with inadequate protein, and a variety of medications. Most hair loss from medications, is this type of hair loss, and the related medications include retinoids, beta blockers, calcium channel blockers, antidepressants, and NSAIDS (including ibuprofen). Supplements that can also cause or increase telogen effluvium are higher doses of iron and Vitamin A.
The hair begins to fall out in differing amounts and can start weeks to months after the initial shock to the body or medication initiation. The hair loss can continue up to 6 weeks and typically slows at 8 weeks after the start of the hair loss.
Weight loss surgical patients experience this due to the stress of surgery and the low protein state directly after surgery. Although there is no specific treatment for Telogen Effluvium, there are steps that can be taken to potentially slow the hair loss and help support the new hair growth.
The most important steps to take are to maintain your protein supplementation at a minimum of 80-100 grams of protein daily and hydration (at least 64 ounces daily) after weight loss surgery.
Protein, particularly L-lysine, are the building blocks of hair and nails, without adequate protein your body will forgo making hair and nails to maintain critical muscle mass. Also hydration is important to flush the body of toxins, due to fat breakdown in the liver during the rapid weight loss phase, that will prevent further new hair growth.
Vitamin B6 and B12 deficits can also contribute to hair loss. Multivitamin supplementation is essential to maintaining the required levels of these vitamins. The recommended multivitamin supplementation is two multivitamins daily that are equivalent to Centrum brand multivitamin.
Some people add Zinc supplements to increase hair production. However, if you are adding Zinc it is advised to also add a Copper supplement as they compete with each other for absorption. Copper is important for red blood cell production and a copper deficiency can exacerbate iron deficiency anemia. Inactivity can also decrease zinc levels, therefore exercise/activity will naturally maintain zinc levels.
Biotin is also a B vitamin that can be helpful in new hair growth.
Folicure is a supplement tablet that contains many vitamins and minerals that some people find helpful for hair re-growth. They also manufacture a shampoo that can be used.
There are many shampoos and topical treatments that people use and report satisfaction in their results. However, it is important to note that a topical treatment may make your hair appear thicker but the hair regrowth will only be supported by internal nutritional maintenance. Minoxidil is a liquid vasodilator medication applied to the scalp that is the exception to this rule and can help with hair regrowth. However, Minoxidil will not work to it’s optimal level in the absence of adequate nutritional status.
We always go back to our basics after weight loss surgery of hydration, protein and exercise to maintain health of body and hair.
Orthostatic Hypotension/Intolerance
August 26, 2014 4:02 pm
One of the possible side effects of rapid weight loss after undergoing weight loss surgery is orthostatic hypotension or orthostatic intolerance. These terms describe a significant drop in blood pressure upon standing from a seated or reclined position. Drip in blood pressure causes a decrease in blood flow to the brain. There are several studies discussing this after RNY gastric bypass and sleeve gastrectomy. However, this can also be an issue post Duodenal Switch. The process is still not completely understood but can be due to several factors. Rapid weight loss, sympathetic nervous system dysfunction, dehydration, electrolyte imbalance, malnutrition, thyroid issues, cardiac issues, post prandial hypotension (blood pressure lowering after meals due to blood flow shifting to the gut) or medications are all suspected as possible causefor orthostatic hypotension.
Symptoms can include dizziness, lightheadedness, nausea, blurry vision, weakness, fatigue, palpitations, headache, exercise intolerance, intermittent confusion and can culminate to passing out. This can be diagnoses with blood pressure monitoring while positioning change, ECG, laboratory studies, echocardiogram, tilt table test and possibly Valsalva maneuver.
There is a direct link between obesity and hypertension. A large number of patients undergoing weight loss surgery are on anti-hypertension medications. Patients need to be followed closely in the hospital and in the rapid weight loss phase post surgery for medication changes and eventually termination of anti-hypertensive medications. Follow up and monitoring with a primary care physician is crucial due to these rapid changes.
Dehydration, anemia, and low protein intake need close surveillance after weight loss surgery. The patient may require laboratory studies to investigate these causes.
Treatments may include increasing hydration, protein intake, changing medications and treating anemia. Also, allowing time for the body to adjust to the rapid weight loss if all the underlying issues are within normal limits. If symptoms persist, after all underlying issues are investigated, the patient will need to be diligent with hydration, protein intake, supplements and other treatments. Things that may also help is to slow down in moving from one position to the other, take a moment to adjust to your new position. Compression stocking and increasing salt intake can also help if all other causes are investigated. Post prandial hypotension can be avoided with low carbohydrate and small meals. Also, moderately increasing salt intake can improve symptoms.
Protein Malnutrition Protein Part 2
July 31, 2014 1:25 pm
Protein energy malnutrition (PEM) or Protein Malnutrition is a problem that can effect a few after weight loss surgery (WLS) and Duodenal Switch (DS). In our previous blog post on protein we discussed the types of essential and non-essential Amino Acids and possible sources. We also discussed how to choose the best bioavailable protein and to vary protein sources to achieve adequate protein levels. There are cases even with adequate protein intake that can result in PEM due to inadequate protein absorption. The early signs of low protein may be low energy, muscle weakness, moodiness, inability to sleep well, joint pain, changes in hair and nails and carb craving. It is imperative after WLS that you maintain your protein levels throughout your lifetime. The minimum protein intake is 80-100 grams per day after WLS. There is no leeway where protein is concerned. It is important in almost ever function in the body.
There are two types of protein energy malnutrition, Kwashiorkor and Marasmus:
Kwashiorkor is a lack of protein intake with adequate or slightly lower caloric intake. It’s symptoms are edema (swelling in legs, ankles, feet) enlarged abdomen, irritability, anorexia, hair discoloration and loss, muscle weakness, changes in psychomotor function, mental lethargy, ulcerations, brittle nails, rash or discoloration of the skin, bradycardia (slow heart rate), non-tender parotid enlargement, enlarged liver with fatty infiltrates that are similar to alcohol liver disease. The edema is caused by osmotic imbalance in the intestinal system causing swelling of the gut. Protein, primarily albumin is responsible for the colloidal pressure within the circulatory and tissue systems. The lack of protein within the circulatory systems cause fluids to “leak” into tissues causing edema. Gastro-intestinal symptoms can include nausea, vomiting, dehydration, diarrhea and increases in appetite. People who have pathological bacteria or parasites and/or after WLS diarrhea can precipitate lower levels of protein. If left untreated can lead to protein malnutrition.
Marasmus is characterized by a lack of protein and caloric intake. The symptoms are an emaciated appearance with edema. There is no liver changes as in Kwashiorkor. This is a starvation mode and can be difficult to treat and can progress to a point of no return.
Catabolysis is the bodies response to lack of protein and or nutrition. This biologic process breaks down muscle and fat to maintain bodily functions. Catabolysis is the body’s last resort to keep it alive. It is a starving body eating itself to keep vital organs alive.
Laboratory Studies are needed to determine the level of malnutrition and treatment routes. These studies include:
- Lipids
- CBC (complete blood count)
- CMP (comprehensive metabolic panel) includes liver and kidney function tests, Calcium and electrolytes
- Albumin Normal is greater than 3.5 gdL (transports nutrients such as calcium, zinc and Vitamin B6)
- Prealbumin (transthyretin) transports retinol (Vitamin A)
- Total protein Normal is greater than 6.3 gdL
- Iron tests such as serum iron, TIBC, and ferritin
- Vitamins and trace minerals such as B12 and folate, vitamin A, vitamin D, vitamin K, B vitamins, calcium, and magnesium
- Ova and Parasite stool testing
Protein is an extremely important nutrient within our bodies and is considered the workhorse in cells and organs. They are responsible for catalysts, messenger duties, structural, immunoprotectors, transporters, buffers, fluid balancers and many other roles. Protein has a hand in synthesizing other proteins, regulates protein turnover, enzyme activity, neurotransmission, gene transcription, transport of other nutrients, messenger and signals for growth hormone and insulin, structure, storage for other nutrients and immunity.
The muscular system is the most obvious structural protein in our bodies, 40% of the total body protein, as is hair, fingernails and cells. Our organs also require protein in order to function appropriately. However, protein’s role in red blood cell formation, size and health is extremely important. If you don’t have adequate protein levels your body can not make red blood cells. Transferrin is a protein that carries iron to receptors. Ferritin is an intercellular protein that stores iron until it is needed. Glycine is a protein for heme synthesis. B12 is also transported via a protein for red blood cell production. Protein is also important in blood clotting and plasma.
Cardiovascular health is also reliant on protein for structure and function. Also, proteins can have a protective effect at the mitochondrial level.
Kidney function relies on protein to regulate the acid base balance and ammonia disposal. The kidneys are also the site of amino acid production.
Protein is also important in bone health as a carrier for Vitamin K and calcium binding, tissue repair, healing and growth. Proteoglycans play a role in extracellular structures such as skin, bone, and cartilage. Also related to the skeletal system are glycoproteins, which also aid in building connective tissue, collagen, elastin and bone matrix.
Central Nervous system relies on proteins for neurotransmission, hormone production and other functions. Protein deficients can lead to neurologic problems such as altered behavior and mental function among other manifestations. The neuorpeptides have actions on transmission functions, mood and behavior. They can also effect a wide range of functions such as blood pressure, body temperature, pain sensation, and learning ability.
Immonoproteins are the group of proteins that provide immune protection such as immunoglobulins and antibodies.
Protein also have storage roles for copper, iron and zinc called metalloproteins. Copper and zinc are considered neurotransmitters, important for iron metabolism, and connective tissue formation in heart, blood vessels and skeletal.
There are situation where your protein needs will increase. In cases of wounds, burns, surgery, stress, sepsis or other illnesses, protein requirements increase. Also age, pregnancy, lactating and increased exercise increases protein needs.
Protein Energy Malnutrition is protein deficit that can and should be avoided after WLS. PEM, if left untreated, can lead to organ failure and death. Protein is crucial in almost every function of the body and without adequate levels there will be symptoms and side effects. Please take care to maintain your protein levels throughout your life. We have discussed several of protein’s function, however, there are many more.