EVALUATION FOR WEIGHT LOSS FAILURE

Evaluating a patient who is progressively regaining weight can be relatively simple – or difficult. The first principle is to determine that the gastric pouch is anatomically intact. If it is not intact, it should be made intact by a revision procedure. Only when the surgeon can be reassured that the pouch in intact does the complex part begin – evaluating how and why the patient is not using the pouch/tool properly, and/or getting a reasonable amount of exercise.

We need to know three things about the small gastric pouch. First, is the staple line intact; second, is the outlet intact; and third, is the pouch reasonably small in size.

The upper GI series is the basic tool for evaluating intactness of the staple line and the outlet. If the pouch has been stapled in continuity with the rest of the stomach (non-transected), we must confirm that the staple line remains intact. A disruption of the staple line will create two gastric outlets leading to rapid pouch emptying, early loss of satiety, and thus early return of hunger.

The upper GI series can usually give the bariatric surgeon a reliable view of the diameter of the gastric outlet also. A diameter of over 18-20 mm is usually associated with weight regain. Outlet failure, like a staple line disruption, causes rapid emptying of the pouch and early loss of satiety, and early return of hunger.

On the other hand, weight regain can occur as a result of an outlet diameter under 7-8 mm which can lead to persistent vomiting of solid foods and gradual persuasion of the patient towards the Soft Calorie Syndrome with resultant rapid pouch emptying, early loss of satiety, early return of hunger, and regain.

The upper GI series is less effective for evaluating pouch volume because of the fact that barium is very much of a liquid. To assess pouch volume, you must turn to the patient’s history of the size of the meal that he/she can consume within a short five to fifteen minute time frame, and/or the Cottage Cheese Test.

Cottage Cheese Test: Measure out a couple 1/2cup servings of cottage cheese. See how much cottage cheese you can eat until you are full (Eat it at a regular pace. It should only take a short time.) The amount you eat until just full is approximately the size of your pouch. Up to 4-6 ounces should be considered average. (1/2 C equals 4 ounces)

In the patient whose gastric pouch seems to be anatomically intact and yet he/she is still regaining weight, the evaluation becomes more complex. The usual finding is that the patient is not following the principles of the use of their pouch/tool and/or is exrtremely inactive physically.

There are four problems that occur with some frequency:

· The patient has never been taught/ or does not understand how to use the tool.

· The patient is significantly depressed.

· Loss of contact with a bariatric practice or other bariatric patients and a gradual erosion of following the principles.

· The patient is truly noncompliant and will not take responsibility for his/her own behavior.

PATIENT DOESN’T UNDERSTAND HOW TO USE THIS TOOL

Patient needs teaching on use of pouch/tool and proper eating habits after gastric bypass surgery. Also attendance at a good bariatric support group is extremely important

DEPRESSION

Depression is a powerful inhibiter of success after bariatric surgical procedures. A small but significant number of patients have been doing well following surgery only to drop out of sight for a time and then reappear with a significant weight regain. Upon evaluating these patients, it would appear that in many instances they seemingly deliberately reverse all of their learned principles of the use of their pouch/tool: grazing and snacking through much of the day, drinking high calorie liquids, drinking liquids with meals, and stopping their exercise, even when they are intellectually aware that exercise in itself releases numerous vasoactive substances which act like antidepressants.

What can be done when a bariatric patient obviously is depressed and regaining weight? Obviously, the most important thing is to steer them to professional counseling, if they are not already in counseling. Then, be encouraging. We can encourage them to continue to use the tool as best as they can; we can encourage them to return to exercise which will improve their spirits and reassure them that the improvement is "deserved," because they really are a good person and deserve to feel better…" Most of all, they need to be reassured that the pouch/tool is not ruined by this overeating and gradual weight regain. When they are ready once again to use their pouch/tool, it will be there for them, and they will be able to once again lose weight without being hungry.

EROSION OF THE USE OF THE PRINCIPLES

In a third subset of weight maintenance failure patients, a subtle weight creep can occur in patients who are otherwise compliant, non-depressed, and have intact pouches. The patient will see it as "struggling" with his/her weight, and by definition, he/she will not have seen their bariatric surgeon for followup visits, and will have usually lost contact with a support group or other bariatric surgical patients. There seems to be a progressive erosion of following the principles of the pouch/tool. This may be due to denial as seen in diabetic patients, or it may be due to the influence of their peer group and the fact that some of the principles of the use of the pouchtool, especially fluid management, are counter-intuitive and counter to behavior of their peer group. The patient will often not come back for evaluation because "I know what I’m doing is wrong!" (meaning that he/she is eating the wrong things and too often), and these patients will internalize their "failure" with an increasing sense of guilt which itself acts as an inhibition to coming back to their surgeon’s office or support group for help. These patients are in need of a "refresher course" in the use of the principles of the pouch/tool. In the first three examples of reasons for failure - lack of teaching, depression, and gradual erosion of the use of their tool, weight once regained can be lost once again if the pouch is anatomically intact and the patient decides to use it, or learn how to use it or relearns how to use it. In these three examples we are working with compliant, reasonably responsible persons who, when they can, are willing to take responsibility for their own behavior.

TRUE NON-COMPLIANCE

The most difficult problem is determining, and being comfortable with that determination, when a patient is being fundamentally noncompliant and obstructive. This type of individual may leave his/her surgeon’s care and go to others complaining about a "personality conflict", or perhaps even that the surgeon has not given them the time and attention that they need and deserve. Inexplicably, some will actually stay with their surgeon. In this instance, when the patient tends to return perhaps even more frequently than usual, depression will be more likely the underlying mechanism rather than noncompliance. It can be difficult to be reasonably sure of what is going on in one or two visits. The truly noncompliant patient will very likely end up with multiple revisions and/or a reversal due to weight regain or complications. This is not to say that someone with multiple revisions and/or a reversal necessarily is noncompliant. The kind of patient who is truly noncompliant is often quite resistant to counseling, but no other management option offers much hope for success. Luckily, this type of patient represents a very small minority of patients.

TUNE UP

BEHAVIOR MODIFICATION

6 Steps to Success

1. Protein (120-180g per day – protein drinks)

2. Vitamins (2 multi vitamin Completes, iron (ferrous fumerate), 1200-1500 mg Calcium Citrate, Magnesium (with the Calcium) NOTE: Do not take the calcium and iron within 2 hrs of each other. Only take 600 mg of calcium at a time. That is all your body can absorb at a time.

3. Water – (minimum 64 oz per day)

4. No snacking

5. Exercise

6. Attitude

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 first 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.

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 the 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 the 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 exercise and diet habits. And even though patients lose weight "no matter what" for the first few months, use of the concepts outlined 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.

For those farther along on this journey… Has your weight loss stopped? Have you started to regain some weight? If the answer is yes to either of the above questions, there are some steps to take to get back on track.

The goals of the long term gastric bypass diet are :

1. Consume minimal calories (promote weight loss)

2. Consume adequate nutrition (achieve excellent long term health)

3. Achieve the two goals above without undue hunger or cravings

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 the satiety signal will continue as long as the stuff is still in the pouch. Therefore, a patient should do the following:

· Don’t change your eating habits at all for the first few days, but write down every single thing that you are eating. Once the habits have been identified, there are steps that can be taken to establish new eating patterns.

· Drink your protein ! ! ! (120-180 mg per day)Why? Even considering that the definition of proximal used by the surgeon varies greatly, in ALL proximal RNY surgeries, the duodenum is bypassed.  In order for dietary protein to be absorbed, it must go through several enyzmatic reactions in order to be broken down into amino acids, which are the only form the protein can be absorbed into the small intestine.  The first and second of these steps are missed  - even in the most proximal RNY.  (1.Acid
breakdown in the stomach, and 2.delivery of bile and digestive enzymes from the pancreas through the duodenum - necessary for protein breakdown)

[This part is in medical-ese, but I can't say it without being so] The two most important proteolytic (protein breakdown) enzymes are secreted from the pancreas in inactive forms - trypsinogen and chymotrypsinogen.  In the duodenum, the enzyme enteropeptidase activates trypsinogen to trypsin, which, in turn activates, among others, chymotrypsinogen to chymotrypsin. The trypsin and chymotrypsin split certain peptide bonds within the protein. Another pancreatic enzyme splits off single amino acids from one end of the protein chains that occur in the digestion process.

Since the chewed food doesn't even start the digestive process (for protein anyway) until it reaches the common channel (where the 2 upper parts of the Y), it has significantly less time to "do its work" and breakdown the dietary protein into the amino acids that we (or anyone) can absorb.  Therefore dietary protein should not be counted for more than 25-50% of its value in the proximal RNY patient.  In the distal patient, dietary protein would not be counted at all.

· Eat 3 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 within 2-3 hours of getting up. It has been shown that absence of nutrient intake(not eating breakfast) causes the appetite center to "gear up" or become more sensitive, resulting in greater overall calorie intake through the day.

· Be creative when cooking. Try spices and share ideas with buddies. Stay away from fast food and also from eating on-the-go.

· Eat only at the dining table or designated place that you eat. Do not eat in front of the television or computer.

· Make sure that you eat your protein first, or at least that you eat the protein before you run out of space. The meal needs to be 75% protein. (Protein stays in your stomach longer and is used by the body to repair damaged cells and to build lean body mass.) However, carbohydrates are broken down into sugar. The body uses what portion it needs for immediate energy and then stores the rest as fat, to be broken down later as it is needed. (WE DON’T NEED THAT!) 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 tend to "rush" into the system and drive the blood sugar up quickly. Because the amount of carbohydrates 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.

· Do not skip meals. Eat at regular times each day, being sure that there are about 5 hours between breakfast/lunch, lunch/dinner, and dinner/bedtime. Example: Do not eat lunch 3 hrs after breakfast, then wait 7 hours for dinner. Your body gets hungry approximately every 5 hrs. Avoid feast or famine…you can become too hungry and overeat, or eat too little and slow your metabolism. During times of famine your body is programmed to do everything possible to hold onto its calorie stores. So the first response of the body when faced with starvation (during times of famine, 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." (Note that the hibernation response can also lead to depression and difficulty interacting with others.) This is why many times it is suggested that if you are on a plateau, but are not eating too much, you should actually increase your protein consumption to trick your body out of hybernation mode. This can also be done by exercise. If the body is treated to regular vigorous physical activity during starvation, its interpretation may be that the person is in need of more energy to facilitate the increase in activity. This upregulation means that more calories are burned throughout the 24 hour period (besides the extra calories burned during the exercise itself) and the person has a significantly increased feeling of energy.

· Use a small plate and small utensils (baby utensils or a pie fork). Pay attention to your body and stop eating at the first sign of fullness.

· Take small bites, eat slowly and chew your food completely.

· Water is very important, so make it a priority. Build to 8 glasses or 64 ounces per day. Pre-load with water. Just as you can avoid severe hunger with proper use of the pouch/tool, it is also necessary to avoid thirst and remain adequately hydrated. Beginning about 2 hours after a given meal, you should begin to drink (zero calorie) liquids progressively. This brisk liquid consumption should finish with a "fluid load" about 15 minutes before you are to eat again. "Fluid load" means to quickly drink as much non-caloric fluid as you can hold on an empty stomach, intentionally stretching your pouch. This maneuver serves to top off your hydration and to send satiety signals to your brain before you eat – this immediate satiety should last for 15-25 minutes and will moderate the pace and amount of your eating. About 80% of the maximum capacity at any given time should be drunk rapidly over fifteen to thirty seconds and then topped off with swallows until full satiety is reached. Patients rather rapidly determine what their capacity is, and it usually is between eight to twelve ounces, whereas food volume is 4-6 ounces. The fluids should not be so cold as to be uncomfortable, but it is not necessary to be warm. The scientific mechanism of this procedure is presumed to be the distention of the Roux limb which then contracts, stopping the progression of fluid downwards and backing up the volume and pressure into the small pouch and, perhaps, even into the esophagus. Some allowance in this system must be made for the time of day. It is a good idea to get fluid in before breakfast, including the water load. It is also OK to wait longer after dinner (three or four hours) before drinking fluids. Fluid loading before each meal helps prevent excess calorie consumption and post meal thirst, but should also be used to alleviate the sensation of hunger when tempted to snack.

· DON’T DRINK LIQUIDS WITH MEALS, and don’t drink for at least 2 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 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). In those early months it is appropriate to begin drinking liquids about 30 minutes after you eat.)

· Exercise (make it fun) walking, swimming, aquacise, dancing, aerobics, personal trainer or whatever you can do to exercise and enjoy it, or at least know that you will enjoy the results. Exercise releases endorphins that give you a natural high. Regular exercise is at least as important to success as following the diet recommendations.

· Don’t weigh yourself more than every 2 weeks. It could lead to frustration!

It is 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!

ATTEND YOUR SUPPORT GROUP AND GET INVOLVED.

WE ARE ALL IN THIS TO HELP EACH OTHER.

GOOD FOODS – BAD FOODS

(for the mature pouch/tool)

The following is a list of some of the foods that are good choices and those to avoid for maximum weight loss.

	GOOD CHOICES	AVOID
Milk and dairy products (good sources of protein, calcium and Vitamin D)	Skim, low fat, buttermilk, low fat yogurt, low fat frozen yogurt	Whole milk,milkshakes, eggnog, chocolate milk, evaporated milk, fruited whole milk yogurt, ice cream, sweetened condensed milk
Protein group (supply protein, B vitamins, and iron. Cheese is also a good calcium source)	Low-sugar, low fat, low-carbohydrate protein drinks, fish, shellfish, eggs and egg substitutes, cottage cheese, low fat cheeses, such as farmer’s, part skim mozzarella, part skim ricotta, regular fat cheese such as cheddar, Monterey Jack and Swiss in moderation, low fat peanut butter, chicken, beef, lamb, pork, ham, nuts, legumes(beans, lentils, peas), beef (or other meat) jerky, very crispy bacon	Fried meats, meats with tough connective tissue, protein drinks and bars containing high sugar, high fat, and high carbohydrates, soft bacon, gristly meats such as Spam Note: egg whites contain the protein, yolks are mainly fat.
Cereal (supply B Vitamins, iron and some protein.)	Low sugar whole grain cereals – cooked or ready to eat	Sugar coated and high sugar content cereals (read labels for hidden sugar content in cereals)
Bread and bread substitutes (supply B vitamins, iron and some protein. )	Breads, rolls, crackers, pancakes, waffles, french toast	Sweet rolls, donuts, cakes, cookies, sweet or iced breads
Potatoes and starches (supply B vitamins, iron and some protein.)	Potatoes - baked, mashed, riced, boiled; pasta, white, brown or wild rice, yams, sweet potatoes, popcorn(plain)	French fries, fried potatoes, candied yams or sweet potatoes, popcorn (buttered)
Vegetables (high in Vit A. Tomato products are good sources of Vit C)	Most fresh, canned, or frozen vegetables (plain); vegetable juices, tomato juice, greens and salads, fibrous vegs if cooked well-such as celery, okra, spaghetti squash, salsa	Vegetables in butter or high fat sauces, vegs fried in butter or oil, salads with high fat dressings, care should be taken with fibrous vegs such as celery
Soups	Broth-based (with care not to overdo it as liquids empty from the pouch easily)	Creamed soups, unless made with non-fat or low-fat milk.
Fruits and fruit juices (Include one citrus juice such as orange or grapeftruit every day as they are high in Vit C)	Most fresh, canned, frozen or dried fruits-unsweetened, unsweetened fruit juice, unsweetened fruit preserves	High sugar or packed in sugar fruits; candied or glazed fruits, care should be taken with fibrous fruits such as rhubarb, some oranges, grapefruit-be sure to chew completely
Fats (Empty calories: Limit intake from this group as much as possible) Note : although some foods such as peanut butter as high in protein, they are also high in fat and care should be taken with these foods.	Olive oil, corn oil, low-fat butter and margarine, low fat mayonnaise, low fat salad dressings, water packed meats such as tuna in water (read labels for hidden fats in foods)	Fried foods, butter, cream, high fat nuts, high fat cheeses, high fat salad dressings, mayonnaise, oil packed meats, such as tuna in oil (read labels for hidden fats in foods) Note: egg whites contain the protein, yolks are mainly fat.
Desserts/snack foods (contain few nutrients and are not required for good health)	Artificially sweetened gelatin or puddings, allowed fruits, sugar free Popsicles, low fat sugar free frozen yogurt, and low fat sugar free ice cream in moderation, vegs with salsa dip, raw vegetables with low fat sour cream dip, celery with cream cheese or peanut butter	Pie, cake, cookies, pastries, sherbet, ice cream, puddings, sugared gelatin, pocorn with butter, pretzels, potato chips, corn chips, high fat nuts, candy
Beverages (alcoholic beverages should only be consumed on a very limited basis)	Water, decaffeinated coffee and tea, calorie free beverages (diet), mineral or spring waters, sugar free soft drink mixes	Regular coffee and tea (caffeine causes dehydration), carbonated beverages (soda), sugar sweetened soft drinks, whole milk, alcoholic beverages
Miscellaneous	Salt, pepper, herbs, spices, vinegar, lemon juice, mustard, catsup, diet syrup, sugar-free gum, sugar free preserves and jams, pickles, relishes, low-cal sugar free hard candy (with care-watch calories)	honey, sugar, molasses. Sweetened jams and jellies, sweetened syrups, sweetened gum, candy

Each patient has certain foods which "don’t agree with me." It is important to recognize tha6t these are usually the very foods which fill up the pouch the fastest! If a bite of a hamburger fills up your pouch and makes further eating impossible, often it isn’t because "the hamburger doesn’t agree with me", but rather, because that small amount of hamburger was enough to fill up your pouch! STOP eating right then and there! To have that "second bite" is often to overeat. Your new restricted stomach can’t handle it – even one more bite will distend the pouch and make you feel miserable. When you have an experience like this (all patients do) use it to learn how much of different kinds of food it takes to feel full. Try to train yourself to recognize an adequate amount of food while it is still sitting on the plate, and avoid that "painful full" feeling altogether.

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