Preparation

For the

Vertical Sleeve Gastrectomy

(VSG)

Mark A. Pleatman, MD, FACS

Minimally Invasive Weight Loss Surgery

43494 Woodward Ave. Suite 202

Bloomfield Hills, MI 48302

Telephone 248-334-5444

Fax 248-334-5484

What you will gain:

A more positive outlook

on life

Improved health

conditions

More energy

Less dependence on

medication

Greater mobility and

flexibility

Learn to make better

lifestyle choices

Look and feel better

Adele Mayerson, MPH Patient Support Coordinator

Cari Rabideau, Surgical Coordinator

Website: www. DrPleatman.com

Email: info@drpleatman.com

A Guidebook for Successful and

Sustainable Weight Loss

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General Discharge Instructions...........................................................................................................................4

STOCK YOUR PANTRY ................................................................................................................................8

DIET INSTRUCTIONS THE DAY BEFORE ..........................................................................................................10

CLEAR LIQUID DIET...................................................................................................................................11

PHASE I – WEEKS 1 AND 2 AFTER SURGERY ................................................................................................12

SOOTHING SMOOTHIES RECIPES............................................................................................................13

PHASE III – SOFT SOLID FOODS – WEEK 5 AFTER SURGERY .......................................................................16

PHASE IV – WEEK 7 AFTER SURGERY AND BEYOND ...................................................................................17

POST-OP WEEK 7 AND BEYOND ..............................................................................................................18

DIETITIAN’S EXPECTATIONS ..................................................................................................................20

NUTRIENT SOURCE LIST...........................................................................................................................21

PHYSICAL ACTIVITY – BURN THOSE CALORIES.................................................................................22

PROTEIN CONTENT OF FOODS ................................................................................................................23

PROTEIN, PROTEIN, WHAT’S THE BIG DEAL? ......................................................................................24

SUCCESSFUL WEIGHT LOSS ....................................................................................................................25

KNOWING YOUR SUGARS ........................................................................................................................25

SUGAR SUBSTITUTES ................................................................................................................................26

BODY COMPOSITION ANALYSIS.............................................................................................................27

HELPFUL HINTS ..........................................................................................................................................28

WAYS TO SABOTAGE SUCCESSFUL WEIGHT LOSS ............................................................................29

CALORIE GUIDE FOR FOODS/FOOD GROUPS .......................................................................................30

LOSING YOUR LOCKS? THESE FOODS CAN HELP.............................................................................................34

Attachments.....................................................................................................................................................36

Table of Contents

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To make follow-up appointments please call

Dr. Pleatman’s office @ (248) 334-5444

All Bariatric Patients:

Surgical Date__________________________

One Week Post Op_____________________ Make appointment today

One Month Post-op________________________

Three Months Post-op______________________

Six Months Post-op________________________

Nine Months Post-op_______________________

Twelve Month Post-op______________________

Please call or email the office with your status of symptoms/status and current weight at these intervals. Your post surgical care is critical to your success.

IMPORTANT – YOUR POST-OP FOLLOW UP VISITS

Dates indicated in the blanks are general dates.

***Note for Out of State patients -

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General Discharge Instructions

You will be given a prescription for pain medication before you leave the hospital.

If you still have a gallbladder, you will be given a prescription for Ursodiol to be taken twice a day for 6 months after your surgery. This will reduce your chances of getting gallstones during the period of time when you are rapidly losing weight. Begin taking this medication a month after your surgery.Dr. Pleatman will speak with you about restarting the medications you were taking before surgery. In general, you should resume all medications you were taking prior to surgery, though all medications should be crushed or taken in liquid form. Avoid the following medications, as they may irritate your stomach pouch and cause ulcers: aspirin, ibuprofen, Advil, Motrin, Naproxen, Aleve, Daypro, Celebrex, or other NSAIDs (non-steroidal anti-inflammatory drugs).

Gas pains are common after surgery. You can take Gas-X or any anti-gas medication containing simethicone.

Constipation is common after surgery, especially if you take narcotic pain medications. If your bowels to not move three to five days after the operation, you make take a dose of milk of magnesia.

It is OK to shower. It is NOT OK to take a bath or go into a pool for at least 3 weeks after surgery. Do not scrub your incisions for at least 3 weeks.Walking 20 -30 minutes is encouraged to decrease your risk of blood clots from forming.Do not drive, operate machinery, or make any major decisions while you are taking pain medication.You should wait about 2 weeks before driving. You must be off all pain medications first! Start with some slow, easy driving – don’t get right on the expressway!You can resume sexual activity 3 weeks after your surgery.

Mild nausea and/or diarrhea is common after surgery. However if you have vomiting or diarrhea lasting more than 24 hours, or if you are unable to keep anything down.? Everyone has abdominal pain after surgery, but this should get a little bit better every day. Call us if your pain is getting worse, not better.If your temperature is greater than 101 Deg. F.Look at your incisions in the mirror every day. It is common to have a few drops of bloody or clear yellow fluid from the incisions. Call us if there are more than a few drops, or if the drainage

Medications:

Activities:

When to Call Your Doctor:

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is foul-smelling, thick, or white. Call us if there is redness in the skin extending more than half an inch from the incision.

Your need to come in for your first follow-up visit about 1 week after your operation. Please call our office at (248) 334-5444 to arrange the appointment, if it has not already been made.If you have a question or problem that cannot wait until your follow up visit, please call us (see below).

The office phone number (248) 334-5444. If you have an urgent problem or question, please contact us at the number above! If it is after hours, call Dr. Pleatman on his cell phone. If your problem is extremely acute (for example, crushing chest pain and shortness of breath) please call 911!

Follow-up:

How to Reach Your Doctor:

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The greatest weight loss typically occurs during the first 9 to 12 months after your procedure. In order to sustain this weight loss long-term, it is critical that one’s behaviors are modified early in the postoperative period.

1. - Protein is found in foods such as eggs, cheese, yogurt, meat, poultry, fish, beans, and protein supplements Hair loss, cracked nails and defective healing and immunity are just some of the side effects of inadequate protein consumption. In addition, protein makes us feel more satisfied for a longer period of time.

2. onsume between 64 and 80 ounces (8 to 10, 8-ounce glasses) of non-caloric, de-caffeinated liquid per day. This should be done slowly and throughout the day. This amount should be increased by 10%-20% when the weather is hot and humid to prevent dehydration.

3. Avoid liquids for a period of 30 minutes before eating and 30 minutes after eating a meal. There will be times throughout the day to consume 16 ounces of fluid within a 90 minute timeframe. This assures that you are consuming about 64 ounces of fluid per day.

4. This rule assures that you are getting all the nutrients and fluids that you need during the day. Stop drinking liquids prior to eating, eat for 30 minutes, and then resume drinking 30 minutes after the meal. Eat five times per day; drink 16 ounces four times per day.

8:00-8:30 AM Eat breakfast8:30-9:00 AM No food or liquids9:00-10:30 Drink 16 ounces of fluid (water preferred)10:30-11:00 No food or liquids11:00-11:30 Eat a snackRepeat this cycle throughout the day

5. Limit yourself to approximately 25 grams of sugar per day. This would include two fruit servings per day. Sugar causes “dumping,” even after sleeve gastrectomy. Dumping is when sugars go directly from your stomach to your small intestine causing heart palpitations (racing heart beats), nausea, abdominal pain and diarrhea. Food products to avoid include: CandyCookiesIce CreamSugary soda pop, juices, gelatins, puddings and most dessertsA list of acceptable sugar substitutes are found in the attachments given to you.

Guidelines to Follow for Optimal

Weight Loss after Surgery

Weight Loss:

Guidelines to Follow for Life

Protein -The primary source of nutrit ion.

Drink an adequate amount of liquid da ily, preferably water. C

Always drink liquids separately from the solid foods you eat.

Follow the 30-30-30 rule!

Typical example:

Avo id sugar. Read food labels carefully!

There are 7 cardinal rules that one must follow in order to attain a weight that is close to one’s ideal body weight.

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6. There are specific enzymes in our saliva that break down the proteins that we consume. The better we chew, the easier it is to digest our foods; therefore the better we feel. Chew your food about 20-30 times per bite before swallowing.

7. Do not “stuff” yourself, as this may cause your stomach pouch to stretch, leading to discomfort and possibly vomiting.

1. Record your protein and water intake. This helps you stay on track and be accountable for how much protein and water you are consuming throughout the day.

2. Maintain a consistent exercise regimen. Movement improves your overall health and helps maintain a healthy body weight. Resistance training 2-3 times per week can improve bone health and tighten up loose skin. It is recommended that for the first 3-4 weeks you start walking 20-30 minutes per day. After 3-4 weeks, you can start a resistance-based workout. Go slow and listen to your body.

Chewable or Liquid Multi-vitamins are preferred for the first 6 weeks after surgery. After then it is acceptable to take vitamins in capsule form.

Both men and women need 1000-1500 mg of calcium per day.

Suggested vitamin protocol:

Chewable: Two per dayOrLiquid: 2 scoops in 16-20 ounces of water per day

Start taking vitamins when you begin your full liquid diet as tolerated.Take them during or after eating a meal to avoid an upset stomach.In addition, take 2000-5000 IUs of Vitamin D per day

Chew, chew, chew! Chewing your foods is key!

Stop eating/drinking before you begin to feel full.

HABITS THAT LEAD TO SUCCESS

VITAM IN AND MINERAL SUPPLEM ENT GUIDE

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It is encouraged that you plan ahead and stock your kitchen with foods that will support your nutritional needs after surgery. The following are suggestions to get you started.

DRY GOODS VEGETABLESWhey protein powder V-8 juiceVitamin/mineral supplements Canned vegetablesNatural peanut butter Baby pureed vegetablesAlmond butterSkim milk powder CEREALSilken Tofu OatmealHerbal teas GritsCocoa powder Cream of WheatBenefiber Kashi Hot cerealCrushed flax seed

LIQUIDS SPICES/FLAVORINGS/SYRUPSHerbal teas Any spice or herb to flavor foodBottled water, non-sparkling Flavor extracts; vanilla/orange/mint/almondCrystal lite True Lemon/limeNo calorie beverages/non-carbonated Torani or DaVinci Gourmet sugar-free

Flavored syrups.

FRUITS DAIRYSugar free frozen fruit Skim milkSugar free canned fruit Almond MilkApplesauce Cottage cheeseBaby pureed fruits Ricotta cheese

Plain non fat yogurtSOUPS Sugar free non fat yogurtLow fat cream based soups Eggs or EggbeatersVegetable soups Silken TofuLentil soups Fairlife Milk (Lactose free)Bean soups LactaidChicken brothBeef brothTomato soupCANNED FOODS Canned MeatBeans Canned white meat/breast of chickenFat free refried beans Canned fish; salmon, tuna, sardinesPasta/tomato sauce

STOCK YOUR PANTRY

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We have provided a list you of the various protein supplements available and are highly recommended for the post-op phase of your nutritional needs. This is especially important for the first two weeks following surgery since you are required to be on full liquids. We realize everyone has a different sense of what tastes good to them. Most of the ones listed below offer an un-flavored powder that you can put in to your own full liquid meals such as in your soup, smoothie shakes, and cereals for example cream of wheat, oatmeal, or grits etc. Then there are pre-flavored choices with a fruit, vanilla, or chocolate you can blend with water, milk, or yogurt that you can prepare very quickly.

Multivitamin capsulesMultivitamin soft chewsCalcium soft chewsENS - Multivitamin, Calcium, & Protein Shake

Protein Berry Shakes, Vanilla, and Chocolate flavorsPermalean Protein Bars

Vanilla and Chocolate – High Protein and Fiber Nutritional ShakesTime Released Protein BlendOrder pre-measured in individual sealed bottles or in bulk form (less expensive)

Protein Powder, unflavored Vanilla, Chocolate, and Strawberry Sorbet flavors

And Chicken Soup

On-line source for many bariatric specialty products.

Found at Costco, Walmart, and Sam’s Club

Protein Supplement Recommendations:

1) Celebrate 877-424-1953 (Available in our office)

2) Permalean - 877-737-6256

3) Fit – 365 - 866-434-8365

4) Unjury – 800-517-5111 (Available in our office)

5) Bariatric Mart - 800-pag882-4830

6) Premier Protein

Website – celebratevitamins.com

Website – Permalean.com

Website – Fit365.com

Website - UNJURY.com

Website – BariatricMart.com

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DIET INSTRUCTIONS THE DAY BEFORE

YOUR WEIGHT LOSS SURGERY

It is important that your stomach is empty at the time of your operation. Please follow these instructions:

1. Drink only clear liquids, such as water, tea, clear soup broth, or other clear juices for that entire day.

2. Around 5:00 pm you should take an adult dose of Milk of Magnesia and can continue to drink clear liquids up until midnight.

If you take heart, blood pressure, breathing or seizure medication, take them the morning of surgery with a small sip of water. (Exception: do not take water pills the morning of surgery).

If you have asthma, use your inhalers and bring them with you.

Diabetic patients: Get specific instructions from your doctor or the anesthesiologist regarding whether or not to take your insulin or oral medications.

If you are taking a blood thinner (i.e. Coumadin or Plavix), make sure Dr. Pleatman is aware and follow his instructions.

Medication Instructions:

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CLEAR LIQUID DIET

At first, take in liquids every ½ hour - about 2 ounces at a time. Then gradually increase your intake of liquids to 6 to 8 ounces every hour.

WATER: PLAIN OR FLAVORED, NON-CARBONATED, NON-SPARKLING. Examples include Fruit2O, Propel, Fuze, Splenderize.

CLEAR BROTHS OR BOUILLONS, FAT-FREE. Such as Swanson, College Inn, Banquet

CAFFEINE-FREE COFFEES AND TEAS – (no milk, cream or artificial creamers)

APPLE JUICE/CRANBERRY JUICE/GRAPE JUICE/ORANGE JUICE – NO PULPHALF STRENGTH. Mix equal amounts of juice and water to make it ½ strength.

CRYSTAL LIGHT (or equivalent sugar-free Kool-aid type drinks)

SUGAR-FREE GELATIN (JELL-O or other sugar-free gelatin brands).

SUGAR-FREE POPSICLES

Drink very slowly and refrain from gulping.

CLEAR LIQUIDS LIST

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PHASE I – WEEKS 1 AND 2 AFTER SURGERY

Dates to Begin Phase I:_____________________________

For the first two (2) weeks after surgery, the Full Liquid Diet, which allows for a broad range of liquids and protein supplements are recommended. Anything that has the consistency that can be consumed through a straw” is a good rule of thumb for what is allowed. However, do not sip through a straw!! A suggested list of full liquids follows.

The goal of the Full Liquid diet is to allow your new stomach and digestive system time to heal properly.

All of these products have been specifically formulated for the bariatric patient.

(Regular and Lactose Free) (any brand) * Great to add to other food to boost protein.

including V-8, V-8 Diet Splash, tomato juice or fresh squeezed.remove vegetables, meat, poultry, seafood and noodles, rice or other pasta

first.Cream of Wheat, Cream of Rice, Oatmeal, Grits, Kashi, or

Ralston. Examples include FairLife, and Lactaid.

. This is necessary to maintain optimal nutrition during this phase of your progressive diet.

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Begin taking your multi-vitamins, calcium and iron daily as directed after 7-10 days. Make sure you chew the vitamins before swallowing them.

FULL LIQUID DIET

Bariatric Advantage products 100% Whey Protein, Beneprotein, Nectar, and Isopure-

Carnation Instant Breakfast Powder or Ready to Drink- Sugar Free OnlyM ilk, Skim/Fat Free M ilk, Instant Non-fat Dry JELL-O – Sugar Free OnlyYogurt – Greek, yogurt or pla in.Vegetable Juices Soups, strained –

Hot cereals, made thin and soupy –

Lactose-free milk.

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SOOTHING SMOOTHIES RECIPES

Using whey protein powder in smoothie, hot cereals and soups will help to ensure your protein intake is adequate. The following are some ideas to give your meals variety. The equipment you will need is a blender, magic bullet, or food processor.

: Add one serving of your protein powder.

You can blend any fruit into the smoothie using, fresh, sugar-free frozen or canned fruit packed in its own juice. Use about ½ cup. Frozen fruit makes a thick smooth drink. When using fresh or canned fruit, add a few ice cubes.

Water, milk, Premier Protein, almond milk.

A Whey based or Vegan protein powder. Follow the directions on the product

You can add just about any spice that your taste buds want. Examples include cinnamon, nutmeg, allspice, ginger, cardamom, fennel, parsley. Start with 1/8 teaspoon and add more to intensify the flavor.

If you need to, add Stevia, Pure Via, or Truvia as necessary.

One to two servings of Benefiber or flaxseed meal can be put into your shake twice per day.The combinations are endless, so get creative and be sure to try the combinations you like.

THE INGREDIENTS:

WHEY PROTEIN POWDER

THE FRUIT:

LIQUID BASE:

THE PROTEIN BASE:

THE SPICE:

THE SWEET:

THE FIBER:

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One scoop of protein powder, ½ cup frozen peaches, 6 oz of vanilla yogurt, 8 ounces of vanilla soy milk, 1/8 teaspoon of cinnamon.

One scoop of protein powder, ½ cup frozen berry blend, 1/4 cup of cottage cheese, 8 ounces of milk, 1/8 teaspoon of nutmeg.

One scoop of protein powder, ½ cup crushed pineapple, 1/3 cup tofu, one cup of milk, 1/8 teaspoon of ginger, add a few ice cubes.

One scoop of protein powder, 1/4 cup canned pumpkin puree, one cup of milk, 2 tablespoons of sugar free maple syrup, 1/4 teaspoon of cinnamon and a few ice cubes.

One scoop of protein powder, one half of an orange, one small jar of baby carrots, 6 ounces of vanilla yogurt, 6 ounces of milk, one half teaspoon of vanilla and a few ice cubes.

Two scoop of protein powder, one cup of almond milk, 1/3 of a banana, one tablespoon of peanut butter and a 4-5 ice cubes.

Adding your protein powder to creamy soups and hot cereals is just as easy. Puree soups and add whey protein, then gently heat. Stir protein powder after making a slurry (mix powder with 3 tbsp water) into hot cereals or soups

JUST PEACHY

VERY BERRY

HAWAIIAN DREAM

CREAMY PUMPKIN

ORANGE CARROT BLEND

PEANUT BUTTER BANANA

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Dates to begin Phase II:____________________________________

You will now progress to a blended/pureed diet. You can now add foods to your full liquid diet. The following is a list for what would be acceptable at this point.

Split pea, Lentil, Vegetable, 98% Fat-free Cream soups.Very ripe banana, applesauce (no sugar added) cooked fruit.

Cooked well, so they are very soft – peas, beans, beets, carrots, squash. Avoid potatoes as they are high in carbohydrates.

Boca Burger or Gardenburger blended or pureed or Tofu which can be blenderized into shakes or soups to add protein.

blenderized to the consistency of pâté or chopped liver.soft boiled or poached.

Eggbeaters, Better than Eggs, etc.1% or fat free.

Peanut butter, almond butter, soy butter: natural, without added sugar.

It is important to chew very well 20 – 30 times per bite. Slow down, take small bites and enjoy your food.

This is necessary to maintain optimal nutrition during this phase of the progressive diet.

At this point (the end of week 4) you should be returning to your normal routine or activities

Each day, plan in advance the meals you will be consuming either at home or when you are out. Include protein, vegetables, fruit, non-fat dairy items and whole grains. This will assure you receive adequate nutrition to maintain your health, give you energy, and feel satisfied after eating.

Do not skip meals, this will begin to lower your metabolism and slow your efforts to lose weight.

RECORD all new foods and any problems you have with them in your Food Diary. Bring this diary with you when you see the dietitian.

CHEW your food very well before swallowing. The consistency of the food should be like mashed potatoes. Make sure that each bite is very small (as if you were feeding a baby) and continue to eat small amounts slowly.

CONTINUE to take your vitamin and mineral supplements as directed for the rest of your life.

PHASE II – WEEK 3 THROUGH WEEK 4 AFTER SURGERY

BLENDED/PUREED DIET

Thicker Soups: Fruits –Vegetables –

Soy Protein:

Poultry or Fish –Eggs, Whole or Whites –Egg Substitutes –Cottage Cheese –Nut Butters –

Note:

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Consume a minimum of 50 gm of protein/day.

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PHASE III – SOFT SOLID FOODS – WEEK 5 AFTER SURGERY

Date to Follow Phase III________________________________________

You have gotten through the most critical stage of your post-op care and you can now return to a more normal diet of solid foods. Keep in mind that you should select as you transition into this phase. Always begin your meal with high protein choices (see list) followed by vegetables, fruit and carbohydrates. This will assure that you have received the most essential vitamins and nutrients to maintain optimal health.

Begin the Soft Solid Diet when you are at approximately Week 5 postoperatively. This diet includes all foods previously mentioned and adds the following:

- including whole eggs, egg whites and egg substitutes (Egg Beaters, BetterThan Eggs, etc.)

–Low Fat or Fat-Free: Cottage cheese, Farmers cheese, Ricotta, Muenster, Havarti, American, Mild Cheddar, and Mozzarella (sliced, shredded and string).

– Chicken and Turkey – white meat only – baked, broiled, grilled, boiled or canned. White Meat chicken in the can is an easy and tasty choice.

– baked, broiled, poached, grilled or canned. Salmon, Tuna and sardines are all good canned choices.

– Peanut, almond, soy, PB2 or sunflower. Smooth variety only –preferably Natural, since the brand names have added sugar.

– Preferably pork or veal. Red meats tend to be harder to digest at this stage – however, you can have any of the prepared baby food meats as they have already been pureed for easy digestion and come in small 4oz jar servings.

Boca Burger, Gardenburger, Morningstar Farms.Cooked or canned – Green beans, wax beans, beets, peas, carrots, squash

or any other non-starchy vegetables. , Cooked canned, or soft skinned fruits such as Applesauce (unsweetened),

peaches, pears, fruit cocktail, apricots, cherries ( if canned – choose those packed in water or light syrup only), bananas, grapefruit and orange sections with membranes removed, ripe melons

– Oatmeal, Cream of Wheat, Cream of Rice, grits and sparing use of barley.

. This is necessary to maintain optimal nutrition during this phase.

You can add protein supplements in the form of protein bars now. Choose those protein bars that meet these guidelines:

Choose bars containing less than 200 calories, 15 grams of sugar, and 8 grams of fat

soft, moist, easily chewable food

Eggs

Mild Cheeses

Poultry

Fish

Nut Butters

Lean, Tender Meats

Soy Protein/Tofu –Vegetables,

Fruit

Cereals/Starches

***NOTE***:

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Take in a minimum of 60 grams of protein per day

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PHASE IV – WEEK 7 AFTER SURGERY AND BEYOND

Date to Follow _____________________

At this point you will have had your six week post-op visit with Dr. Pleatman and if you have tolerated all of the earlier phases well, he will suggest you advance to this phase - a more regular diet. Please read the list below for instructions:

Add fruits, vegetables and carbohydrates with fiber i.e. Kashi cereal, shredded wheat with bran, 100% whole wheat pasta, brown rice, ground flax seed.

Eat foods of normal consistency – you no longer have to puree or blend your foods.

Go slowly with dense foods, high fiber foods, doughy breads or stringy, tough meats.

Avoid doughy breads and stringy tough red meats.

Follow the 30-30-30 rule for life.

70-80 grams/day. 80-90 grams/day.

Always eat your protein first.

Still avoid sweets, fatty foods and calorically dense (high calorie) foods that have no nutrients.

Maintain your fluid intake, 9-10 glasses of fluid a day.

Continue with your multi-vitamins, B12, and calcium.

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MAINTAIN ADEQUATE PROTEIN – Women: Men:

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POST-OP WEEK 7 AND BEYOND

Contains 7 grams of protein per 1 ounce.

These foods are good sources of protein, B vitamins and iron.1 oz. = ¼ cup cooked meat; includes beef, fish, turkey, chicken, pork and veal. Meat must be very moist and tender. (A good way to insure this is to cook the meat in a crock pot or pressure cooker).

Also included in this group:2 Tbsp. smooth, natural peanut butter, soy butter, almond butter.1 oz. low-fat luncheon meat, i.e. turkey breast, lean ham, “soy” meats1 oz. low-fat or non-fat mild cheese.¼ cup (1 oz.) low-fat or non-fat cottage cheese.½ cup cooked dried beans (lentils, vegetarian baked beans, etc.)¼ cup tofu, hummus

NOTE: Red meat may be difficult to eat. Always choose a more tender cut of meat. Make sure to cut it into pieces the size of a thumbnail. To add flavor and/or moisture, you may add non-fat gravies, low-fat mayonnaise or Miracle Whip or Worcestershire sauce or steak sauce to moisten.

Contains 4-6 grams of protein per serving. Choose 2-4 servings a day.

These foods are good sources of protein, calcium, Vitamin D and riboflavin. ½ cup 1% or Skim milk½ cup 1% or Skim Lactaid milk (milk with the milk sugar, lactose, removed).3 Tbsp. instant non-fat dry milk powder.½ cup light, low-fat, sugar-free yogurt (without seeds).½ pkg. Carnation Instant Breakfast – No Sugar Added.½ can commercial diabetic formula, like Glucerna½ cup sugar-free pudding.

Choose 1 – 3 servings daily.

These foods are good sources of vitamins, minerals and fiber; also low in calories. ½ cup cooked or raw vegetables = 1 serving.½ cup vegetable juice (ex. Tomato, carrot or V-8) = 1 serving. ½ cup pureed vegetable soup

Choose 1-3 servings daily. These foods are a good source of vitamins, minerals and fiber; also low in calories.

¾ cup raw fruit = 1 serving.½ cup cooked fruit or canned in their own juice = 1 serving.½ cup unsweetened frozen fruit

MEAT GROUP:

MILK GROUP:

VEGETABLE GROUP:

NOTE: At first limit salads to ½ cup or less because, though they are very low in calories, they take up volume in your small stomach pouch, leaving less room for you to eat protein packed solids.

FRUIT GROUP:

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These foods are good sources of energy, B vitamins and iron.

SOUP1 cup of soup (broth-based). Stay away from high fat soups such as chili, french onion, cream chowders and cheese. There are many low fat pureed type vegetable soups available.

STARCHY VEGETABLES1/3 cup starchy vegetables like: peas, winter squash, potatoes –white, sweet or yams.

CEREALS½ cup cooked cereal like: oatmeal, grits, cream of wheat or rice.¾ cup unsweetened dry cereal like: Special K, Shredded Wheat, Heart to Heart, All-Bran. Cereal choices should have less than 8 gms of sugar and have more than 5 gms of fiber per serving.

CRACKERS, PASTA, RICE4-6 whole grain crackers½ cup cooked pasta – preferably 100% whole wheat pasta (Barilla plus)½ cup cooked rice, preferably brown rice. Many people find it hard to digest pasta and/or rice – so make sure the rice/pasta is

very moist.

BREAD – Make sure you are only choosing whole grain breads. This means that it must be made from 100% whole grain flour – not refined or enriched. You may add bread to your diet, however try toasted bread first. You may only be able to eat ¼ to ½ slice of bread at first. You may also find it easier to consume whole wheat pita, tortillas or lavash since these are flat breads and have less bulk than loaf bread.

Choose no more than 3 servings a day.

These foods are low in vitamins and minerals and high in calories. They contain 9 calories per 1 gram of fat, as compared to both protein and carbohydrates which contain 4 calories per gram.

1 teaspoon butter1 teaspoon mayonnaise or Miracle Whip.1 Tablespoon low-fat mayonnaise or low-fat Miracle Whip.1 Tablespoon oil-based salad dressing.1 Tablespoon gravy.1 Tablespoon ground flax seed.1 teaspoon olive oil.

STARCH GROUP:

FAT GROUP

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DIETITIAN’S EXPECTATIONS

AS A BARIATRIC SURGERY PATIENT, YOU MUST COMPLY WITH THE FOLLOWING:

CONVERT to sugar-free beverages. Do not drink your calories. There are many to choose from, i.e., Crystal Light, Fruit2O, Propel Fitness Water as well as many other non-carbonated, sugar-free beverages.

REDUCE your caffeine intake to a maximum of one cup daily. Caffeine acts as a stimulant as well as an irritant to the G.I. system.

REDUCE your refined sugar intake. Use approved sugar substitutes. Ex. Stevia

EXERCISE PLAN. Have some form of physical activity in place. Do it automatically. Walking is acceptable for most. Exercise 20-30 minutes every day.

AVOID chewing gum and sipping from a straw. This introduces air into your stomach. Do not gulp; sip beverages slowly. This reduces air in your stomach.

DAILY take a high-potency multiple vitamin supplement, preferably a vitamin specifically designed for bariatric surgery patients. Ex. Celebrate Vitamins.

DAILY take 1500 mg of calcium supplement containing Vitamin D with 400 I.U., preferably calcium citrate – in a liquid or chewable form.

REMEMBER protein first, followed by vegetables, fruits, dairy, whole grains and good fats. Enjoy your meals.

SMALL frequent meals (4-6); liquids between your meals.

Follow the 30-30-30 rule and chew each bite 20 to 30 times.

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NUTRIENT SOURCE LIST

As a bariatric surgery patient, we want to make sure that you are getting enough vitamins and minerals from the foods you eat. So here is a list of food sources high in calcium, iron, Vitamin B12 and Vitamin C.

Milk, cheese, yogurt, Sardines and Salmon with bones, Perch, shrimp, Tofu, fortified soy products, Almonds, Dark leafy vegetables, bok choy, broccoli, collards, kale, turnip greens, fortified orange juice.

Eggs, poultry, fish, fortified soy products, beefLegumes (black-eyed peas, chick peas, great northern beans, lentils,Lima beans, kidney beans, pinto beans, split peas, soybeansBeet greens, broccoli, chard, green peas, baked potato, spinachDried fruit (peaches, apricots, raisins) prune juiceWhole grain breads, fortified whole grain cereals

You can increase the absorption of plant iron by including foods thatare high in Vitamin C.

Milk, cheese, yogurt, meat, fish, poultry, eggs, Fortified soy milk andSoy analogs, fortified whole grain cereals.

Oranges, broccoli, grapefruit, and kiwi fruit, potato, tomato, cabbage,Green and red peppers, cauliflower, cantaloupe, mango, papaya,and strawberries.

NUTRIENT FOOD SOURCES

CALCIUM

IRON

VITAMIN B12

VITAMIN C

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PHYSICAL ACTIVITY – BURN THOSE CALORIES

The higher the intensity of your work-out, the more calories you burn helping to take off that excess weight. Below is a useful chart that gives you an idea of the number of calories you burn per activity. The calorie values listed below are approximate and can vary on the intensity or the activity.

Raking, active gardening, recreational sports like Softball or Volleyball, golfing (no cart!), weight lifting = 1 calorie/minute.

Walking, moving the lawn, tennis, biking, light aerobics, in-lineSkating, calisthenics = 3 calories/minute.

Moderate jogging, stair machine, racquetball, swimming = 7 calories/minute.Fast jogging, stair climbing, cross-country skiing (outdoor or

machine), jumping rope = 11 calories/minute.

120 lbs. 1 cal/min 4 cal/min 8 cal/min 13 cal/min140 1 5 9 15160 2 5 11 18180 2 6 12 20200 2 7 13 22220 2 7 15 24240 3 8 16 27260 3 9 17 29280 3 9 19 31300 3 10 20 33320 4 11 21 35340 4 11 23 37360 4 12 24 40380 4 13 25 42400 4 13 26 44420 5 14 28 46440 5 15 29 48460 5 15 30 51480 5 16 32 53500 6 17 33 55

INTENSITY/EXAMPLES OF PHYSICAL ACTIVITYLOW INTENSITY:

MEDIUM INTENSITY:

HIGH INTENSITY:

VERY HIGH INTENSITY:

Your Weight Low Intensity Medium High Very High

23

PROTEIN CONTENT OF FOODS

Chicken, white meat 3.5 oz. 25Turkey, white meat 3.5 oz. 21Cod fish 3.5 oz. 21Tuna, canned in water 3.5 oz. 28Egg, cooked 1 medium 7Peanut or Soy Butter (natural) 2 Tbsp. 10Beef, lean 3.5 oz. 25

Milk, skim (Cow’s) 1 cup/8 oz 8Milk, powdered, skim 1/3 cup 8Cheese, cottage 1% or fat-free ¼ cup 7Cheese, cheddar, fat-free 1 oz. 7Cheese, American, fat-free 1 oz. 7Cheese, mozzarella, part skim 1 oz. 8Cheese, ricotta, part skim ½ cup 10Yogurt, low-fat, plain 1 cup 12

Lentils, cooked ½ cup 8Lima beans, cooked ½ cup 8Red kidney beans, cooked ½ cup 8Soy beans, cooked ½ cup 10Almonds/Walnuts 1 oz. 6Cashews 1 oz. 4Peanuts 1 oz. 7Tofu 4 oz. 9Soybeans ½ cup 10

Oatmeal, (not instant) cooked 1 cup 6Rice, brown, cooked 1 cup 5Whole wheat bread (from 100% whole wheat flour) 2 slices 6

Vegetables, raw ½ cup 2Vegetables, cooked ½ cup 2Fruit ½ cup 2

FOOD SERVING SIZE PROTEIN (grams)

MEAT/FISH

DAIRY

BEANS/NUTS

GRAINS/CEREALS

VEGETABLES/FRUIT

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PROTEIN, PROTEIN, WHAT’S THE BIG DEAL?

Protein plays a vital role in providing our bodies with the essential building blocks (amino acids) necessary to sustain all living things. Second only to water, protein makes up the largest part of our body.

If our body doesn’t get enough protein through our diet, we cannot properly build new healthy cells and tissues. When our bodies do not get enough protein, then growth is restricted, wounds do not heal as quickly or as well as they should and we become much more susceptible to infections.

When our bodies do not get sufficient amounts of protein in our diet such problems as general weakness, loss of muscle, brittle nails and most common, hair loss, occurs. Even though dietary protein will not directly increase the size of our muscles, it will help avoid further muscle tissue loss that occurs during periods of bed rest, stress, injury and illness. BARTIATRIC SURGERY is an example of such trauma that, without sufficient amounts of protein, can cause wasting of the muscles and the need for more energy.

The effect of BARIATRIC SURGERY on your body increases the need for protein intake, which, in the initial post-operative period, can only be accomplished through liquid protein supplements, due to the new small-sized stomach.

But how much protein does the Bariatric Surgery Patient need on a daily basis?

(Refer to protein needs at each Diet Phase).

RECOMMENDED DAILY PROTEIN REQUIREMENTS

Average Bariatric Patient Ideal Bariatric Patient

WOMEN 60 gms/day 80 gms/day

MEN 70 gms/day 100 gms/day

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SUCCESSFUL WEIGHT LOSS

KNOWING YOUR SUGARS

Sugar is a carbohydrate that is often added to foods to give it better taste, but it also adds lots of calories! In the case of Roux-en-Y gastric bypass patients, may cause “dumping syndrome” – a condition of moderate to severe abdominal pains and cramping, followed by diarrhea, nausea, sweating, general weakness and dizziness.

- sugar - candy - jam- honey - syrup* - preserves- molasses - cookies - cakes pies - doughnuts - sweet rolls- chocolate - ice cream - sherbet- fruit ice - Jell-O* - pudding*- frozen yogurt - fruit yogurt - milkshakes- fruit juices - fruit canned in syrup- sugared gum- sugared cereals - soda pop* - fruit drinks with sugar- sweet liqueurs - sweetened cocktail mixes

*products made with sugar

Common sugars added to food include: white sugar, brown sugar, raw sugar, Corn syrup, honey, and molasses.

Hidden sugars – Dextrin, Dextrose, Lactose, Maltose, Polyol, Sucrose, Fructose,Turbinado (cane), Xylitol, Galactose, Sorghum, Fruit juiceConcentrate, High fructose corn syrup

AVOID THESE HIGH CALORIE, CONCENTRATED SWEETS

SUGAR BY ANY OTHER NAME IS STILL SUGAR

26

SUGAR SUBSTITUTES

Most of the following sugar substitutes can be tolerated by most patients after surgery and contain little to no calories. The following is a list of sugar substitutes and their brand names:

Aspartame Equal or NutraSweetAcesulfame K Sweet One, SunnetteSucralose SplendaSaccharin Sweet’N-Low, Sweet-10, Sugar Twin

Sprinkle SweetStevia Opti-SweetSorbitol*Mannitol*

*sugar substitutes – in the form of sugar alcohol - may cause diarrhea if usedtoo often in a day. Limit your use of foods containing these sweeteners. Product labels will indicate the amount of sugar alcohol contained – limit to 4 gms or less.

One of the biggest problems bariatric surgery patients face is boredom with their diet. We get many complaints about the lack of variety and flavor, especially withthe protein supplement shakes and drinks. Fear not – we have the answers !

These syrups and flavorings are made with SplendaAnd contain NO CALORIES, NO CARBS, NO SUGARContact: 1-800-775-1925 or www.torani.com

Made with Splenda. Contains NO SUGARS, CARBS OR CALORIESContact: 1-800-640-6770 / www.davincigourmet.com

Both of these companies make a variety of syrups/flavorings which mix well with any liquid including coffee, tea, water, milk and in combination can create wonderful flavorful drinks that take away the same old, same old taste. They can also be used in cooking and baking and are a wonderful addition to any kitchen. Talk to our staff to find out more about these products.

: Your taste buds may change after surgery therefore your desire for sugar may decrease.

SUGAR SUBSTITUTE BRAND NAME

PRODUCTS THAT ADD FLAVOR AND SWEETNESS

TORANI Sugar Free Syrups:

DAVINCI GOURMETSugar Free Syrups: .

Note

27

BODY COMPOSITION ANALYSIS

The following is an explanation of the print-out we get every time you are weighed here in Dr. Pleatman’s office.

Total body weight includes bones, muscle, fat, water, etc. (Whenever you are weighed, we always allow 2 pounds for clothing.)

BMI stands for body mass index. The BMI correlates physical stature and body weight with mortality ratios, i.e. diabetes, cardio-pulmonary disease, cancer, etc. BMI is recognized as a valid assessment tool in identifying obese individuals. Body Composition Analysis may provide more information regarding actual changes in composition over an extended period of time.

Basal Metabolic Rate measures the energy expended by the body to maintain normal body functions such as respiration and circulation.

Measured in Ohms, the impedance value reflects how hard a mild electrical signal has to work to travel through the body. Lean mass (containing water and electrolytes) conducts the current, while fat mass acts as a resistor to the current. A standard range for impedance is 200-600 ohms.

Actual fat mass (in pounds) in the body.

Free Fat Mass (in pounds) is comprised of muscle, bone, tissue, water and all other fat free mass in the body. A healthy ratio for Fat Free Mass to Fat Mass is approximately 5:1 for females and 7:1 for males. Generally speaking, males carry more muscle than females, therefore they will report a higher FFM.

Total body Water (in pounds) reflects the amount of water in the body. To monitor hydration level, use the following formula: TBW/Weight x 100 = % Hydration. According to dialysis standards, women should be approximately 50-60% hydrated, and males should be approximately 60-70% hydrated.

UNDERSTANDING THE TANITA SCALE

WEIGHT:

BMI:

BMR:

IMPEDANCE:

FAT MASS:

FFM:

TBW:

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HELPFUL HINTS

To make rice more palatable, add a small amount of fat-free gravy to eat.

When stir-frying, double the amount of liquid.

Add milk to scrambled eggs to make soft and fluffy.

Limit the amount of sugar alcohol in products to those containing 4 grams or less.

Protein bars should have less than 15 grams of sugar and less than 8 grams of fat.

Have 5-8 grams of fat per meal. (See hand-out on healthy fat choices)

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WAYS TO SABOTAGE SUCCESSFUL WEIGHT LOSS

like Coke, Pepsi and other soda pop, Kool-Aid and sweetened fruit juice.

such as cookies, cakes, pies, candy, potato chips, cheese puffs, Twinkies, cupcakes, fried food, regular ice cream, milk shakes, pizza, etc.

Just a few more bites at each meal can cause extreme discomfort and vomiting.

Some people are tempted to eat only 2 or 3 times a day. This may decrease your metabolism and slow your weight loss. It may also prolong or prevent healing and recovery after surgery due to a decreased intake of nutrients.

Not drinking the required amount of fluid daily can dehydrate you and make passage of food through your digestive system much slower and more difficult. In addition this can also lead to constipation.

Just as important as your eating habits are your exercise habits. In order to burn up extra calories and fat it’s necessary for you to move – move – move. A regular exercise plan helps you drop those extra pounds while toning your muscles and giving you a feeling of well-being. You will also find it’s a good way to work off stress and help you sleep at night.

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Drinking regular sweetened beverages

Eating high calorie snacks or foods

Overeating

Skipping your small meals.

Drinking too little.

Too little or no exercise.

30

CALORIE GUIDE FOR FOODS/FOOD GROUPS

More water = fewer calories per cup.More leaf, stalk, or other “filler” = fewer calories per cup.More starch = more calories per cup.More sweetness (sugar) – more calories per cup.

More water = fewer calories per ounce.Less water (more starch) = more calories per ounce.More sweetness (sugar) = more calories per ounce.More fat = more calories per ounce.

As fat content increases, calories per ounce increase. As a general rule, as color darkens, calories per ounce increase. This applies to fish, poultry and red meats (the darker the color, the higher the fat content.Poultry without skin has fewer calories than with skin.How you cook these foods can change the calorie levels.When fat and/or breading is used in preparation (ex:frying)calorie values are multiplied by approximately 1.5 to 4 times (ranges: fish = 4x, chicken 2-3x, beef = 1.5x).Eggs are 45 calories/ounce; most eggs are approximately 2 oz. = 90 calories per egg.

VEGETABLES: Calories per 8 Ounce Cup (Volume)

Lettuce Summer Squash Broccoli Onions Winter SquashCornPopcorn (no oil)

Guidelines

FRUITS: Calories per Ounce

Lemon Melon Apple Grapes BananaAvocado Dried Fruit

Tomato Pineapple (Potato)Orange

Guidelines

MEAT, POULTRY, FISH, DAIRY: Calories per Ounce (raw starting weight)

White Fish Dark fish (Salmon) Lean red meat Red meat Fatty red meatShellfish Poultry (with skin) (hamburger, Cheese (prime rib, PateCottage cheese Organ meats lean ham) sausage)

Guidelines

10 25 40 65 100 135

5 10 15 20 25 45 85

25 50 75 100 125

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As fat content increases; calories per ounce increase.

As fat content increases, calories per level tablespoon increase.One cup = 16 tablespoons

As alcoholic content and/or sweetness increases, calories per ounce increase.

BAKED GOODS: Calories per Ounce

Whole wheat bread Muffins Cold cereal Cake Potato chips NutsButter

Sugar Pastry ChocolateCookies Pie crustCrackers

Guidelines

CONDIMENTS: Calories Per level Tablespoon

Vinegar Ketchup Sour cream Sugar Salad dressingButter Oil

Mustard Jelly MargarineCream cheese MayonnaiseGravy Peanut butter

Guidelines

B EVERAG ES: Calories per Fluid Ounce

Tomato jui ce Soft drinks Whole milk Eggnog Light cream Heavy cream

NON-ALCOHOLICALCOHOL IC Beer Wine Sherry 80 Proof Gin Liqueurs

RumVodkaWhiskey

Guidelines

70 100 110 125 150 175 200

2 15 30 50 75 100 125

5 12 20 40 65 100

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Vegetab leHot & SourChickenWonton

Cream of MushroomMinestroneCornCream of tomato

French OnionNew Eng. Clam ChowderChili (w/beans, less meat)Cheese

Chili (more beef)

Problem-solving is a particularly important part of using this page. There are greater calories ranges in recipes and prepared combinations than in simpler foods.As fat content increases, calories per cup increases.

CarrotsBroccoliMixed

BerriesFruit Salad

Broccoli with butter

Potatoes

Fruit with cottage cheeseApplesauce

Broccoli with cheese sauce

Potato salad

French fries

Waldorf saladDried Apricots

Potato salad with heavyMayo

Rais ins

Problem-solving is a particularly important part of using this page. There are greater calorieranges in recipes and prepared combinations than in simpler foods.As fat content increases, calories per cup increase.

PREPARED FOODS – SOUPS: Calories per 8 Fluid Ounce Cup (Volume)

50 100 250 350 660 2000Low Calorie Medium Calorie High Calorie Very High

CalorieExtremely High Calorie

Water Based Soups:

Milk/Tomato Based Soups:

Fat/Cream-Based Soup Heavy Fat Soups

Guidelines

PREPARED FOODS – VEGETABLES AND FRUITS: Calories per 8 Ounce Cup (Volume) 25 100 250 350 600

Low Calorie Medium Calorie High Calorie Very High Calorie Extremely High Calorie

Veg/No Fat

Fruits/No Fat

Veg/Some Fat

Starchy Veg/No Fat

Fruits + Fat/Sugar

Veg/Heavy Fat

Starchy Veg/Some Fat

Fried Veg

Fruits+Heavy Fat/Dried

Starchy Veg/Heavy Fat

Small, Packed Dry Fruit

Guidelines

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Problem-solving is a particularly important part of using this page. There are greater calorie ranges in recipes and prepared combinations than in simpler foods.As fat content increases, calories per cup increase.

Potatoes 120Oatmeal 130Pasta 150-200Fish 150-225Rice 200Beans 180-250

Poultry 225-260Frozen Yogurt 250Pasta + tom sauce 250Potato salad 250-400Ice Milk 275Pasta & 8 meat sauce 350

Fried Rice 400Pasta+cheese sauce 400-500Beef, chuck 300-450Beef, ground 400-600Ice cream 350-600

Gravy 400-800Nuts 650-925Cheese fondue 680Mayonnaise 1,600Butter 1,600Oil 2,000

Problem-solving is a particularly important part of using this page. There are greater calorie ranges in recipes and prepared combinations than in simpler foods.As fat content increases, calories per cup increase.

Pasta, rice, potatoes, beans

Fish, shellfish, light poultry

Shellfish with vegetab lesChicken with vegetab les

Cottage cheese, yogurt

Starch with meat sauce, casseroles, potato salad, baked beans

Dark poultry, veal

Beef, pork with vegetables

Frozen yogurt, ice milk

Fried rice, refried beans, pasta and cheese sauce

Beef, pork, fried shrimp

Sweet & sour pork, beef & been burrito, lasagna

Ice cream, pudding, mousse

Gourmet ice cream

PREPARED FOODS STARCH, PROTEINS AND DAIRY: Calories Per 8 Ounce Cup (Volume)

25 50 100 250 350 600 2000

Guidelines

PREPARED FOODS – ANCHOR POINTS: Calories per 8 Ounce Cup (Volume)

25 50 100 250 350 600 2000Low Medium Calorie High Calorie Very High Calorie Extremely High

Calorie

Guidelines

Low Calorie

Medium Calorie High Calorie Very High Calorie Extremely High Calorie

Starch/No Fat

Lower Fat Proteins

Low/Med Fat Proteins +Veg/No Fat

Lowest Fat Dairy

Starch + Fat

Medium Fat Proteins

High Fat Proteins +Veg/No Fat

Lower Fat Dairy

Starchy + Heavy Fat

High Fat Proteins

Ethnic High Fat Combos

High Dairy Fat

Highest Dairy Fat

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LOSING YOUR LOCKS? THESE FOODS CAN HELP

TODAY

U pda te d: 11:25 a .m. ET Ja n 25, 2007

Healthy hair depends on the body’s ability to construct a proper hair shaft, as well as the health of the skin and follicles.

Therefore, good nutrition assures the best possible environment for building strong, lustrous hair

However, changing your diet now will affect only growth, not the part of the hair that is already visible. In fact, starting a

hair-healthy diet today will mean a more gorgeous head of hair within six months to a year, depending on how fast your hair

grows. Hair growth varies between ½ and 1 ½ inches per month (depending on personal differences). On average, a person can

expect to have about 6 inches of new growth every year, so it will take about that long to notice the effects of your nutritional

changes.

Before discussing how nutrition helps hair, it’s important to point out what nutrition help:

Thinning hair due to male pattern baldness cannot be helped with nutrition. Your best bet is to catch it early and speak

with your doctor about medication.

Thinning hair due to aging cannot be helped with nutrition. As we get older our hair spends more time in a resting phase

-- versus a growing phase, which leads to thinner, slower growing hair.

Hormonal shifts – women tend to notice hair changes during pregnancy, postpartum, and nursing.

Stress is one of the most common causes of reversible hair loss.

Several medications can cause temporary hair loss. Thyroid conditions (hypo or hyper). Low ferritin level (low

reserves of iron).

Protein is necessary for all cell growth, including hair cells. Hair gets its structure from hardened proteins called keratin. Without

enough protein for keratin, hair grows more slowly, and the individual strands that do grow will be weaker.

Furthermore, the iron found in animal protein (called “heme iron”) is most easily absorbed by the body (more so than the iron in

plant foods (non-heme iron). Iron helps red blood cells carry oxygen to all cells in the body, including the hair follicles.

Diet tips for more luxurious hair from TODAY nutritionist Joy Bauer

If you're tried every shampoo, conditioner and cream hoping for thick, shiny hair, you may be going at it all wrong. The truth is,

eating the right foods will not only help you feel great but they'll give you luxurious locks as well. TODAY nutritionist Joy Bauer

has some advice for getting "ahead" in the hair game.

new

cannot

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Other conditions that negatively affect hair – but are all reversible, include:

After ruling out medical and stress related conditions, here’s my recipe for a Healthy Hair Diet!

Iron-rich protein

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For most people, foods can provide all the iron necessary for good health and strong hair. However, before menopause, women

may want to consider taking a standard multivitamin that contains the daily value for iron. Never take straight iron pills without a

doctor’s supervision – taking excessive amounts when your body is not deficient can be detrimental to your health.

Good sources of iron-rich protein include clams, oysters, lean beef, turkey, duck, lamb, chicken, pork, shrimp, and eggs.

Good sources of vegetarian iron rich protein include tofu, soybeans, lentils, beans, and black-eyed peas

Vitamin C improves the body’s ability to absorb non-heme iron (also known as vegetarian based iron), so vegetarians should eat

iron-rich vegetables and foods rich in vitamin C .

Vitamin C is also used to form collagen, a structural fiber necessary for the body to maintain integrity by holding it all together.

Hair follicles, blood vessels, and skin all require collagen to stay healthy for optimal growth of beautiful hair. Good sources

include guava, peppers, oranges, grapefruit, strawberries, pineapple, papayas, lemons, broccoli, kale, and Brussels sprouts.

These vitamins are involved in the creation of red blood cells, which carry oxygen and nutrients to all body cells, including those

of the scalp, follicles, and growing hair. Without enough B vitamins, the cells will not thrive, causing shedding, slow growth, or

weak hair that is prone to breaking.

Good sources of vitamin B6 include fortified whole-grain breakfast cereals, garbanzo beans, wild salmon, lean beef, pork

tenderloin, chicken breast, white potatoes (w/skin), bananas, and lentils.

Good sources of Vitamin B12 include shellfish (clams, oysters, and crab), wild salmon, fortified whole-grain breakfast cereal,

soy milk, trout, lean beef, and low-fat cottage cheese.

Good sources of folate include fortified whole-grain breakfast cereals, lentils, black-eyed peas, soybeans, oatmeal, turnip

greens, spinach, green peas, artichokes, okra, beets, parsnips, and broccoli.

The mineral zinc is involved in tissue growth and repair, including hair growth. It also helps keep the oil glands around the

hair follicles working properly. Low levels of zinc can cause hair loss, slow growth, and dandruff. Good sources of zinc

include oysters, lean beef, crab, ostrich, pork tenderloin, peanut butter, wheat germ, turkey, veal, pumpkin seeds, chicken, and

chickpeas.

For more information on healthy eating, visit TODAY nutritionist Joy Bauer’s website at www.joybauernutrition.com

Vitamin C

B-vitamins—folate, vitamin B-6, vitamin B-12

Zinc

at the same meal

36

What We Expect of You A

Weight Loss Surgery Preparation Class B

Words to the Wise C

Useful Information D

Your Daily Routine E

More Tips to Assist with Weight Loss F

Useful Tips for Maximizing your Digestion Potential G

Exercise, Part of your Weight Loss Plan H

UFO’s – Unidentified Fitness Obstacles I

Fitness Assessment and Testing J

Support Group Topics K

Websites for Tracking your Weight Loss Progress L

Article: After the WLS Honeymoon (From Obesityhelp October 2012) M

Article: Bariatric Weight Gain (from Obesityhelp March 2013) N

Pre-Surgical Requirement (copy of form that you signed) O

Attachments

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Attachment A

Keep all office appointments: It is important that we monitor your progress, on a regular time scale. One week, six weeks, three months, six months, 18 months, and yearly. You are responsible for scheduling and keeping these office appointments.

Take your vitamins every day. Multivitamins and Calcium are very important nutrients that your body will need for the initial healing and thereafter. They are especially important during the first year following surgery and the dosage may need to be modified. Please consult with a dietician.

Exercise every day. Walk swim, ride a bicycle, join an aerobics class, do something physical for at least 30 minutes daily. Exercise helps tone your body muscles and decrease "sagging". It is also a great way to relieve stress.

Faithfully attend support group meetings. These are very important for the information you receive and for the group support you receive.

Please come in at regular intervals (ex. monthly) to get your body weight composition. Our office is open every weekday from 9:00 to 5:00 pm. Just stop in and we can do this without an appointment.

Keep in mind the surgical procedure you have selected is a tool to be used along with your active participation in healthy food selections, regular exercise, and implementing lifestyle changes that will help promote your weight loss efforts.

Follow the dietary guidelines recommended by Dr. Pleatman and his support staff.

Please contact Dr. Pleatman's office if you have any questions, concerns, or require clarification. We are available during office hours to respond to you promptly.

What we expect of you:

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Attachment B

We have planned this session to inform you of what you can do to prepare for your weight loss surgery and your post-op care. Below are some of the highlights we will review in this class.

Realize that you are giving yourself an opportunity to improve your physical condition, have more energy, increase your longevity, and have a renewed outlook on your life.

Personal commitment from you is necessary to comply with all aspects of weight loss support program. (Refer to list of What We Expect of You)

The benefits you will receive after undergoing surgery will not occur automatically. You must become an active participant and have a deep sense of wanting to improve your current health conditions, feel and look better. This won't happen without you altering your current life, follow the guidelines we discuss today and review reading material given to you.

Presently there are many Internet web sites, chat rooms, and information that you could obtain about weight loss surgery. Be aware that some of this information could be incorrect and would like you to let Dr. Pleatman and his staff clear up any concerns or questions you may have. Contact him via our e mail at info@drpleatman.com.

Read and understand the Surgery Prep handbook and other handouts we have supplied. Aftercare is extremely important once you undergo weight loss surgery. Adherence to these guidelines is strongly recommended.

If you don't already have a routine exercise plan you may want to get a fitness evaluation. After completing this, an exercise physiologist will determine and design an exercise program suitable for your fitness level. We can help you set this up.

We have a secret Facebook Group named Dr. where we announce Support Group Meetings and where you can also safely share your experience with our other patients. You may post anything from photos, recipes, or helpful tips. This Group is totally invisible to the rest of the world and you must ask us to add you to the Group.

Weight Loss Surgery Preparation Class

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• Pleatman’s Surgical Patients

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Attachm ent C

Surgery is the tool; your head does the work.

Remember protein 60-80 grams a day.

Drink water separately from eating.

Do physical activity 5 out of 7 days a week.

Focus on changing eating habits not results.

Forget how you ate before.

You are not cured.

Weight loss is the easy part.

Maintenance is hard.

Have automatic behaviors like healthy food choices, daily fitness.

Make small changes.

"Inch by inch it's a cinch" "Yard by yard it's too hard."

Figure what to do with your hands.

Be patient with yourself and have a balanced view of things.

Surround yourself with what you need to do to achieve your goals.

Make a commitment to do the work

Weight Loss Class

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Attachment D

Useful Information

In the first few weeks following surgery you may feel tired, have insomnia, and even have nausea. Sticking to the suggested food guidelines at the pace recommended from week to week will get your stomach to gradually adjust to the changes occurring with respect to your weight loss.

If the surgery is working as it should, you are forced to eat less. Listen to your body and stop when you are full. Also try and accept the foods you once were able to eat cannot be tolerated by your body anymore. These are internal messages to you to consume food that is generally healthier for you. Utilize this opportunity while your body is assisting you to change your food habits. Begin to appreciate the benefits you will receive from this new beginning you have been given. If you follow the suggested guidelines you will begin to see the results.

As you begin to feel better you may need to remind yourself to eat your 3 meals a day. You are getting back into your normal routine and may forget to eat regularly. Do not go longer than 5 hours between eating. Eat slowly and chew your food well.

In the first 9-12 months your weight comes off at the fastest rate. You don't want to be eating foods that will slow that process down. You will never have the opportunity to relive those first rapid weight loss months again.

A weight loss plateau is where your body stops dropping the weight. This is very common and happens to almost all of the patients at one time or another. If you have had this excess weight for years then losing a large amount of weight is a temporary stress on your body. You can also experience hair loss from this new "stress" you are experiencing from all of the changes you are undergoing since your surgery, for example your food consumption is much lower and other adjustments you have had to make.

Realize that this will not be permanent

Be sure you are drinking an adequate amount of water (64 ounces/day)

Eating foods that are within the guidelines (proteins/vegetables)

Step up your exercise level

Make sure to get adequate sleep (7-8 hours/night)

You are undergoing changes and you should give yourself a lot of credit for all of your efforts. Arrange an activity that you really enjoy and plan for these celebrations as you adjust to all these new changes. See a movie, attend a concert, walk through a beautiful garden, or arrange a fun event with a friend. In other words indulge yourself and treat yourself well.

A.

B.

C.

D.

E.

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Attachment E

Your Daily Routine

Set yourself up for success by doing the following:

Take required vitamins and minerals

Drink plenty of water (constantly be sipping a non-caloric drink)

Select nutritious food to eat

Exercise for at least 1/2 hour, three times/week. Include stretching, toning, weight bearing,

and aerobic exercise into your routine.

Set aside time for your enjoyment.

Other important reminders:

Please check our Facebook Group often to find up-to-date information on our support

group meetings.

Put us as the sender into your e mail contact list, so we will be recognized by your server.

Send us a note to confirm your exact e mail address at

info@drpleatman.com

Attend our monthly support group meetings, scheduled on our Facebook Group.

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Attachment F

More Tips to Assist with Weight Loss

Move throughout the day, walk, stretch your muscles, and rotate your joints. Avoid being sedentary.

Exercise at least three times per week for one hour or 10 — 20 minutes daily. There are many websites that allow you to download short exercise videos. You can find videos in the On Demand section on your Cable TV. There are many categories to choose from for example, Balance and Body Sculpt, Building Muscle, and Yoga and Pilates. (See attached sheet from the home page of this website)

A session that is at least 1/2 hour in length will cover the three essential components of fitness:Aerobic or Cardiac ConditioningStrength Training — muscle enduranceFlexibility — Range of Motion and stretching

Eat a healthy snack or meal every 3 hours. This corresponds with the length of time your stomach takes to digest food and then requires refueling.

Eat in a relaxed environment, chew slowly, and eat until your stomach is about 3/4 full.

To help maintain a healthy body, take the prescribed amount of vitamins and minerals formulated for bariatric patients.

Be gentle with yourself and leave sufficient time to check stress levels in order to keep your mental and physical state in balance.

Seek out a support group or like minded friends that will support or motivate you to maintain a healthier lifestyle.

Get a restful 8 hours of sleep. Set aside time to doThree part breathing deep into your diaphragm.Yoga, aromatherapy, meditation,Connect with your outdoor environment.Listen to music for inspiration and relaxation.

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Attachment G

Eat only when you are truly hungry (once you are past 1 month post-op period)

Don't eat again until the previous meal is digested

Avoid large amounts of liquid, right before, after or during a meal

Avoid very ice cold foods and beverages

Chew all your food very well

Avoid large quantities of raw and uncooked food

Do not eat when you are upset

Eat much, much slower than you would normally

Balance your mental activities such as reading, sitting at your computer, TV or movie watching with

physical activity

Eat the freshest foods possible to assure getting sufficient vitamins and nutrients from your food choices

Eat in a settled, quiet atmosphere with a calm mind

Eat at approximately the same time each day

Sit for a few minutes after a meal before returning to an activity

Your food should look appetizing and be pleasant tasting

Try not to eat very close to your bedtime, no late night eating

Useful Tips for Maximizing Digestion Potential

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A National Institutes of Health Survey of 13 studies concludes that physical activity:Results in modest weight loss in overweight and obese individuals

Increases cardiovascular fitness, even when there is no weight lossCan help maintain weight loss

New theories focusing on the body's set point (the weight range in which your body is programmed to weigh and will fight to maintain that weight) highlight the importance of exercise. When you

reduce the number of calories you take in, the body simply reacts by slowing metabolism to burn

fewer calories. Daily physical activity can help speed up your metabolism, effectively bringing

your set point down to a lower natural weight. So when following a diet to attempt to lose weight,

exercise increases your chances of long term success.

Examples to get you started:

Park at the far end of parking lots and walk Take the stairs instead of the elevator

Cut down on television

Swim or participate in low-impact water aerobics Ride an exercise

bike

Overall, walking is one of the best forms of exercise. Incorporating exercise into your daily activities

will improve your overall health and is important for any long term weight management program,

including weight loss surgery. Diet and exercise play a key role in successful weight loss after

surgery.

After recovering from your surgery, approximately 2 – 4 weeks, begin an exercise program that

incorporates the following:

Frequency, plan to exercise at least 3 times per week.Intensity of your workout you select should be determined by a fitness evaluation of your

current physical condition and increased graduallyTime, the period of time you devote to a workout out session.

Attachment H

Exercise as Part of your Weight Loss Plan

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Attachment I

We all have a wide range of characteristics, preferences, and limitations which produce exercise relapse. All of us suffer from one or more of these factors at any one time.

1) Negative emotions2) Injury

3) Poor social support4) Low motivation

5) Stress

Sports Psychologists refer to the stages we follow when deciding to act on something we desire to change as

"Trans Theoretical Model of Change"

Pre-contemplationContemplationPreparation Action Maintenance

You can fluctuate between these stages at anytime, such as one step forward, two steps back pattern.

Where are you in this fitness process?

According to Bess Marcus, PhD — Director of Physical Activity Research at Brown University read below:

Optimally we all want to be in the last stage of this process, the maintenance stage.

We develop barriers either real or imagined that have us constantly moving through these phases. These mental barriers develop by setting too rigid a goal for ourselves. For example: "I don't have an hour to devote to exercise, so I won't do anything at all."

I have to walk for an hour every time I walk, but I don't have an hour. So I guess I will just not do anything and try to fit it in tomorrow.

So therefore you become easily discouraged when falling out of a pattern you thought you had established for yourself.

Unidentified Fitness Obst

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Connect with your own sense of purpose when engaging in an exercise program

1.) You want to look better2.) Training to become more versatile at a given sport3.) Get more energy

4.) Change your clinical profile — Heart rate, blood pressure, percent body fat 5.) Improve your overall health

You do not want to be overly ambitious and set your goals too high especially when you are facing steep weight or fitness challenges.

Running has always been shown to be the best form of aerobic exercise. So then if you cannot run, should you choose to do nothing?

You can receive the same benefits from walking, hiking, swimming, wall climbing, stair stepping, elliptical training, rowing, jumping rope and mat (ex. Yoga or Pilates) classes.

Your heart has no preference of "How you work out," just that do some form of work.

Don't continue to just keep doing what you already know you like… Expand your horizons, be adventurousYour body will respond more effectively when trying something new and exerting other muscles that are under used.Bring in new exercises graduallyDo it too slow and your body will not be challenged and then change. Like using the same weight each time, gradually build up to higher weights.Your body desires to seek new physical challenges. This will keep you balanced, stimulated, and moving forward, not stalling out.

If you don't plan now for your future physical fitness, you may not realize what you may be doing is passively planning, if you don't exert any effort, a lifetime of

Poor health Less able to manage stress Constantly have an out of shape feeling Prone to other health complications as you age

Suggestions:

Have exercise be an integral part of your life.

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Attachment J

Why Perform a Fitness Assessment?

Before a client begins an exercise regime or significant weight loss it is recommended that the client their physician for a signed physician release form.

It should include a complete medical history; an informed consent. This will help to identify individuals at risk for cardiovascular, musculoskeletal or other health issues. Fitness tests measure a client's ability to perform physical work, screens the client for injury prevention and risk factors and will assist the client evaluate related lifestyle and wellness issues.

Benefits of a Fitness AssessmentHelps establish the client's current health status and provide you with baseline information.

Provides extremely useful information for comparison later as the client progresses and improves.Serves as a powerful and educational motivating tool, thus increasing the likelihood of adherence.Demonstrates your professional discretion and knowledge.

Components of a Fitness Assessment

Medical History FormAnalyze risk factors

Physician's clearance form or sign off signature per clientProvides preliminary information to client

Informed consent form

The Fitness Assessment

Resting heart rateResting blood pressureWeight and body fat3-Minute Step TestMuscle strength and enduranceAbdominal endurance

Flexibility

Interpretation/Coaching Session Set Reasonable Expectations

Short term and long term goals and dates

Fitness Assessment & Testing

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Attachment K

Support Group Topics

Dietician, Nutrition Essentials for Bariatric Patients

Nutrition specialists

Exercise Physiologists

Psychologists

Former Patients who have reached their optimum weight

Motivational speakers

Physical Medicine or Rehabilitation Medicine Specialists

Physical Therapists

Strength and Conditioning Trainers

Yoga or Pilates Instructors

Aquacise instructors who can discuss the benefits of non-weight bearing exercise in the

pool.

Low fat/no sugar cooking demonstrations

Clothing Exchange/ Fashion Show

Body Image presentations

Creating a Personal Journal

Other Suggestions:

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Attachment L

Websites for Tracking your Weight Loss Progress

www.Fitbit.com

www.Realself.com ***

www.bariatricpal.com

www.SparkPeople.com

www.livestrong.com

www.FitDay.com

www.choosemyplate.gov/SuperTracker

www.WeightWatchers.com

www.ObesityHelp.com ***

www.MyFitnessPal.com

www.Caloriecount.about.com

www.loseit.com

Tracking your progress will hold you more accountable and give you a historical perspective of your weight loss journey.

For those of you who use Facebook, Dr. Pleatman has a Facebook Page titled “Mark A. Pleatman MD.” If you “Like” this page, you will be notified of important events such as Support Group Meetings. You will also be notified when Dr. Pleatman posts research articles that may be of interest to you.

There is also a private Facebook Group titled “Dr. Pleatman’s Surgical Patients.” By joining this group you will be able to connect with our other patients and share your experience with others who are taking this same journey as you. You will be notified via email of our monthly Support Group Meetings and can reply if you are going to attend. This group is invisible to the rest of the world; please ask us to add you to this Group if you would like to be a member.

****Also, please go to the VSG forum on the Realself and ObesityHelp websites, and select “Find a Surgeon,” (Dr. Pleatman in Michigan) and post a review of your surgical experience with Dr. Pleatman, his office staff, and the hospital. We very much appreciate your taking the time to do this.

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Connect with Dr. Pleatman on Facebook

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The first 12 months after my surgery, my WLS honeymoon was magical. I felt like a child, discovering everything for the first time again and loving it! It was like getting a second chance at life. I was very fortunate because my obsessive thoughts about food completely lifted for a period of time. I was given this gift of ease around eating that I had never experienced before.

My cravings and head-hunger left, and my body began to move more easily as the weight began to melt away. My mobility and stamina steadily increased, and I began experiencing a level of joy, contentment, and excitement about life that far surpassed anything I could have ever hoped for.

I was on top of the world! I thought that WLS finally solved my life-long struggle with obesity once and for all. But then, out of nowhere, my obsessive thoughts began to sneak back in. Head-hunger returned, and the urge to see what I could get away with eating crept back into my experience. My WLS honeymoon had ended.

What I didn't realize at the time, and what I now know to be true for anyone looking to sustain long-term success, is that WLS is a temporary solution to a chronic and often recurring problem. Here's the big secret that no one tells you: WLS can help you get thin, but it will not keep you thin. You need to keep you thin because everything that got you fat before can get you fat again. Without a secondary intervention that targets and transforms the mental, emotional, and behavioral patterns that led to obesity in the first place, you are at significant risk to regain the weight or substitute another (equally dangerous) addiction in place of eating.

It doesn't really matter what triggers the return of the obsessive chatter and constant negotiation in our heads about what we can and can't eat (or buy, or drink, etc.). It could be stress at work or in our relationships, it could be financial pressures, or the loss of a job or a loved one. It could be anything. What matters is what we do when the obsessive thoughts return.

Three Critical Skills For Success After the WLS Honeymoon

1. Listen to the Wisdom and Truth Your Body Offers

What's the most fattening thing that someone struggling with obesity can do?

Exist on a steady diet of distraction. Although our bodies are a constant source of information, most of us learned long ago to tune our bodies out. Why? Because distraction takes us out of a present (potentially painful) experience, and it allows us to focus elsewhere so we can feel safer and less vulnerable in the moment. The tradeoff is that by allowing ourselves to be distracted, we deny ourselves access to the vital information our body tried to give us in the first place. Information that could have helped us move healthfully and productively through the problem, instead of side-stepping it.

Attachment M

After The WLS Honeymoon Is Over

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We most likely learned to distract ourselves, or check out of our bodies, in order to cope with something traumatic. Maybe it was a family tragedy, or abuse of some kind, or medical or psychological pain (like feelings of depression or loneliness), or maybe we felt isolated like we didn't belong anywhere. Whatever the reasons, and there are many good ones, we learned that we could manage physical and emotional pain by tuning in to something else, something less stimulating, and less scary. This was a valid and sometimes life-saving strategy when we were young. But as adults, this same strategy can kill us.

So it's not the chocolate or the pizza that is our ultimate downfall. It's maintaining habits and behaviors that support this lack of tuning in and listening to our bodies.

We can't afford to be asleep at the wheel anymore. We need to be conscious of the choices we make from moment to moment. Our choices will either move us closer to sustaining the new found health and weight loss we worked so hard to achieve, or further away from it.

2. Learn to Identify and Express Your Feelings and Needs

Once you understand that your body is giving you valuable information, and acquire the tools to tune into that information, you need to develop the skills to identify and express your feelings in order to ferret out your needs. Your feelings are clues, or real-time indicators, of how close your choices and actions are to meeting your underlying needs. If you don't learn to identify your feelings, flesh out your underlying needs, and develop healthy strategies to meet those needs, you may reflexively resort back to meeting your needs through addictive or compulsive behaviors.

For example, when a client of mine had a recurring lunch date with a particular friend, she often came away upset from overeating. She had no idea why she would stuff herself whenever she saw this particular friend. Through our work together, she learned that her need was for connection and companionship, but because her friend frequently received cell phone calls during lunch, or brought her young daughter with her to their lunch date, my client didn't end up getting what she wanted: connection. So instead, she settled for what was familiar: comfort in the form of food.

Once she got clarity on the need she was trying to meet, she was able to tell her friend how much she missed their time alone together (creating more connection), and directly asked her friend how she would feel about not taking calls when they meet. She also asked what time might work better than lunch for them to get together alone. In other words, she found a way to get her need for connection met in a direct, respectful way for both parties. She no longer had to resort to indirect strategies that met secondary needs (like comfort) by continuing to show up for their weekly lunch and ordering something that made her feel better in the moment, but regretful later.

Whenever we feel regret, rather than fulfillment, we are usually doing something that doesn't give us what we really wanted in the first place, which in the above example was connection. Learning how to meet our needs directly is both critical and particularly challenging for those of us who've had WLS. We've often trained ourselves to stuff our primary needs and settle for secondary needs like comfort and protection. The solution is not to disown or hate ourselves for having needs; it is to access healthier ways or strategies to meet our needs directly.

3. Develop a Compassionate, Respectful Stance Toward Yourself

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Most of us have been conditioned from birth to compare ourselves to others. We often bounce between criticizing and judging ourselves and blaming others. We are encouraged to think in terms of false dichotomies, such as right and wrong or winner and loser. This way of thinking about the world becomes our reality, the norm. And yet this norm often creates internal and external conflict, hinders communication, and tends to create misunderstanding and frustration in ourselves and others. It also makes heart-felt connection more difficult, and true self- expression feels like a heroic act instead of a normal, healthy choice.

The biggest acts of bravery that you can perform are learning how to stop judging and comparing yourself to others and developing that part of yourself that acts in your own best interest. You can learn to advocate in a caring and loving way for yourself and others, and live in alignment with your core values and beliefs. This is not selfish and does not require you to ignore anyone's needs. In fact, once you learn to do this properly, you will be amazed at how doing so makes you more grounded and actually brings you closer to the people in your life.

The Weigh to Optimal Success

WLS is a temporary window of opportunity to help you shed the physical weight. To sustain weight loss long-term, you need to take just as much action, with just as much personal conviction, to shed the emotional weight. If you wait for the return of cravings or food obsession to develop the health- based strategies you need to respond to yourself and others in a compassionate way, you may have waited too long.

You have so many choices now; don't let regaining the weight or developing a substitute addiction be one of them! Be prepared, so you can keep the weight off after the honeymoon ends. Do what it takes to act in your own best interest and reestablish trust in your body. If you listen to what your body is saying, and learn how to be your body's best advocate, you will become the person inside that cansupport your new and changing body for the duration!

About the Author

Jill Temkin, founder, Living Thin Within, has an MA in Psychology and is a Registered

Addiction Specialist, with 30 years of experience working in the mental health and

addiction fields. Jill established Living Thin Within in response to her own journey for

support after WLS. Her mission is to help women thrive in their new bodies by learning how to sustain health and happiness from within. ??

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It may be surprising for patients to learn that weight regain after gastric bypass is the most common post-operative complication. Many patients are told about the possibility of blood clots, leakages, or other surgical complications but the topic of regain is rarely discussed in detail. When the topic is broached it is usually given as a stern warning with no real support mechanism to help prevent the complication. These warnings are disguised as "make sure to follow the program regimen or you will regain". What happens when a person follows the program regiment perfectly and still regains? Then what? That is what this article will discuss.

Regain and its stigmata, for better or worse, have at its core an assumption that the patient failed to comply. In most cases this assumption may be true. However, to say that all regain is associated with non-compliance of a regime is to say that all obesity is causedby chocolate. The reason for regain varies as wildly as the reasons for obesity itself.

Non-compliance occurs when a patient fails to follow the regime set-forth by his/her surgeon. The programs are designed to help guide the patient to lose weight and therefore failure to follow the regime may result in weight regain. The amount of weight regain can vary depending on the severity of the non-compliance.

If a patient is only gaining slight amounts (less than five pounds) the surgical office or general physician might not consider this actual regain. Body weight can fluctuate up to five or more pounds on any given month. However, any regain that continues should be discussed with a physician.

One problem with non-compliance is the accuracy of the data. Most patients do not record in detail (or honestly) their food records. This makes the diagnosis of noncompliance difficult. However, if a patient has continued to gain weight for a period of more than 60 days the patient needs physician (or support system) intervention.

Another problem with non-compliance is the consistency of the regimes within the industry itself. Many patients will seek out other post-ops to help them with the surgery journey only to find that practice requirements (regimes) can be drastically different from surgeon to surgeon. This can exacerbate an already challenging life journey. The best rule of thumb in dealing with informational sources is to cling to your own surgeon and his / her regime. However, the program should be flexible enough to support individuals with needs that might fall outside the norm.If you are a patient, you are following your program regime, and you are still gaining weight please keep reading as not all regain is due to non-compliance. There may be physiological issues that are causing your regain.

The 'honeymoon' phase of weight loss occurs generally in the first 12 - 18 mouths post-surgery. During this time many patients have been quotes as saying "I could have drank a milkshake twice a day and still lost weight". This may be true. The initial physical shock to the system produced by the surgery

Attachment N

Bariatric Weight Regain

Non-Compliance:

The Honeymoon is over:

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causes what might be called a "reset" to the system. This is very much like flipping the breaker on a power box_ The body simply resets itself and begins to relearn how to function with the new physiological make-up. This period is known to post-ops as the honeymoon phase.

This is the time when patients enjoy the most physical weight loss and the amount of work required is normally much less. Most patients record weight loss with little or no effort. Once the honeymoon is over many post-ops begin to notice that weight loss stops completely or a slight regain takes place. This is normally when most post-ops begin to panic and seek help online. This is a dangerous time for any post-op. The post-honeymoon phase is also the time that hunger or 'cravings' return. This is the body's way of saying, "I am done resetting myself and I would like some of my old favorites please".

Be careful in this post-honeymoon phase. This is w most regain begins. A pound here and a pound there ads up over time and before you know it, you've gained thirty pounds. One way to avoid post-honeymoon regain is to weigh yourself weekly, record your weight, and avoid the old foods (triggers) that caused your obesity. "Trigger foods" are foods that do not satisfy hunger but instead food a craving. Trigger foods can include: bread products, chocolates, chips, cookies, ice cream and any other product that has low protein and high calories.

When your surgeon performs an operation on you they will do so with the best of his ability. For the most part (99%) of surgeries are performed nearly the same way. This “one size fits all” seems like the right choice because it offers the greatest degree of expected outcome. However, you are as unique as your fingerprint and your biological make-up means you might fare very well with one surgery type but not another. What does this mean to you? This means you and your surgeon should discuss the best option for you. No guarantee can be given because despite our best efforts to make one surgery fit all cases, this simply is not the reality of obesity.

Obesity is caused by many factors and is affected via regain by many factors. You may experience regain because your surgical choice was not the right choice for your body and that cannot always be known prior to surgery. One thing that surgeons will not tell you is there is a science and an art to practicing medicine. The science means there is a set of rules to be followed but the art means there are times when you have to adjust the rules to fit the patient. Your regain might not be your fault. There may be a need for a second procedure. Your condition may require your pouch to be smaller or may require a revision with a different surgery type. Many post-op patients consider 'revision' equal to failure and that is simply not the case. Revision surgery exists to help continue you on the journey of proper weight management and if you find yourself in this scenario, please do not allow the fear or stigma to stop you on your journey.

This condition exists when the surgery type chosen by you and your surgeon fails to help you achieve a healthy weight. There is no one set answer here but any scenario that does not allow you to reduce your BMI to a safe level is either an incomplete solution or requires further intervention (surgery, medication, diet and exercise). You will need to consult your surgeon if you feel your surgery has been a failure. Your surgeon may ask very tough questions about your compliance, your habits, and your lifestyle.

Your Unique Situation:

What is a Weight Loss Surgery Failure?

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If you are to be successful, you have to be prepared to be honest with your surgeon and yourself. If you have not been able to reduce your weight below 35 BMI or you have regained weight above a 35 BMI, then you should consult your weight loss surgeon.

You should not feel shame for regain. Shame is not going to help you rebuild your self-esteem. Shame or guilt will not help you gain control of poor eating habits that might have crept back into your life. Instead of shame or guilt, you should feel pride in your achievements.

If you lost 100 pounds only to regain 20 pounds then you are still down 80 pounds! This is a remarkable achievement and do not allow yourself to feel shame. Consult your surgeon, a dietitian, or other support person. The fact is, you may have gained muscle mass and not fat. Do not allow the scales to be the only method of measurement. Never allow the scale to be your measure of self-worth and never allow the scale to determine your success. Instead, measure your success in the amount of life achievements you can now accomplish.

Should You be Ashamed of Weight Regain?

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Patient Name _________________________ Date _________________________

Attachment 0

43494 Woodward Ave. Suite 202 Bloomfield Hills, Ml 48302

pleatmanoffice@comcast.net

Please Read and Sign Below

Please strictly adhere to the diet restrictions set out in your Post-op surgery manual and follow all other information contained in this booklet.

It is imperative once you are released from the hospital if you feel anything unusual when you are at home to notify Dr. Pleatman of any of the following:

Fever

Nausea

Pain

Restriction or choking when ingesting liquid

Not tolerating the required diet

Or any other signs or symptoms not considered normal for you

It is better to be on the safe side and not delay contacting Dr. Pleatman and possibly have your symptoms become worse. He is on-call and available to meet any of your urgent needs day or night. Call the office and you will be directed how to reach the doctor. You may also email him with your questions or concerns that are not of an urgent nature.

With regards to your Primary Care Physician:

If you are currently seeing other medical specialists for your general medical care or other chronic conditions, continue to do so after surgery. Please inform Dr. Pleatman at your post-op office visits if your overall health status or prescription medicine changes.

I have read and understand the above notification.

Mark A. Pleatman, MD

248-334-5444Email:

Pre-Surgical Requirement

Patient Self-Care after Weight Loss Surgery

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Notes