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Saturday, June 24, 2006

Live from Fairfield...

I attended today's ObesityHelp Regional Seminar in Fairfield. I can't even begin to describe how impressed I was by the all-day event. This seminar was small with a handful of vendors manning booths with lots of samples and a series of lectures delivered in the same room. There were about 200 people in attendance, some from as far away as Utah.

I apologize ahead of time for any typos; I blogged directly from the event and pushed each segment live without running spell check. If you find fewer than 10 typos, I think I did pretty well.

For those of you pressed for time or just not interested in wading through the details, let me sum up some of my favorite parts of the day:

For the most part, I enjoyed all of the speakers. However, I was surprised by new information a few of them provided. I learned about a new bariatric procedure called vertical sleeve gastrectomy. A less invasive version of bariatric surgery, the vertical sleeve gastrectomy can be done more safely on high-risk patients and features a faster recovery time (see notes on Dr. Cirangle for more information). Another surprise was learning that peanut butter isn't considered a high-protein food. This is terrible news for the woman who often licks peanut butter from a spoon in the name of lunch. Not only is the fat content in peanut butter so high that it outweighs the protein benefit, but the protein in peanut butter isn't easily absorbed. There goes my favorite convenience food. The final, most profound, news I heard was that a runny nose, sneezing and hiccups after a meal are signs of overeating.

The beauty of attending a bariatric seminar is that there is no anxiety when lunch time comes. I wasn’t worried that the menu wouldn’t be pouch-worthy. And boy, was I not disappointed.The only plates at the buffet were salad plates, which is important for me. I tend to be a member of the clean-your-plate club, and large-size dinner plates entice me to overeat. Salad plates ensure proper portion control. Lunch was a variety of salads: a curried chicken salad, tuna salad, a selection of cheeses, fruit and a mixed greens salad. Everything was tasty and perfect.

Interesting people
I talked to a few people who attended the seminar to get themselves back on track after regaining some of the weight they lost through surgery. One woman, four years after surgery, has put back on 45 pounds. Though she is still smaller than she was before surgery, she recognizes the fact that her previous size is just around the corner if she doesn’t gain control.

She says that her body tolerated junk food better than protein-rich foods, and she took to eating those more than good-quality foods. She stopped taking vitamins, stopped supplementing with protein, started drinking with her meals, etc.

She said one of her main mistakes was to start thinking of herself as “normal” and acting as if she was an average person. It’s taken her a long time to accept that she’s not normal and never will be. To get herself back on track, she’s started taking a doctor-prescribed appetite suppressant. She says it helps her use her tool the way it was created to be used.

“The big disappointment with weight loss surgery is that it doesn’t fix the daily struggle you fight each day.”

Another testament to it not being brain surgery.

Another interesting point that came up was how many of us blame so much of life’s challenges on being overweight and expect those challenges to disappear with weight loss. But that doesn’t happen. After surgery, your spouse may still belittle you, you’re still going to be insecure and you’re still going to face all of the same emotions you had before. The difference now is that you can’t eat to cope with those problems.

Vendor faire
The vendor faire, though small, offers some great information and features. has a sampling of products available at its online store. Everything from books to MedicAlert jewelry to hygiene helpers are showcased.Another booth offers a plethora of samples from Bariatric Advantage vitamins and Body Choice protein pudding (12g).

The Body by Katzen booth features numerous photo albums of work by Dr. J. Timothy Katzen, a Beverly Hills cosmetic surgeon who will also speak at today’s event. I even got the opportunity to see breast and buttock implants. The buttock implant is hard as a rock. Gives new meaning to the term “buns of steel.”

Dr. David Elliot of Healthy S.T.E.P.s Weight Loss Center, is a Santa Rosa bariatric surgeon who will also speak today. Dr. Elliot spent 20 years in the U.S. Army and was introduced to bariatrics while studying under another surgeon. He’s been performing gastric-bypass surgery on his own for the last six years.

Lauralyn Bellamy of Embody Success is a life coach who will also speak today. She’s a post-op who specializes in helping other post-ops adjust to life as thin people.

The most popular booth of the day is probably the one with Achiev One. Only available online, either through the company directly or through bariatric Web sites such as Account Exec. Fernando Vasquez had samples of almost every flavor. He was missing my favorite – cappucino. Of course, I shouldn’t complain. After all, my pouch doesn’t even like decaf coffee, and the Achiev Ones do have a small amount of caffeine from the real coffee used as flavoring in them. The drinks are similar to store bought Starbucks Frappucinos, except that they offer 20 grams of protein in each 9.5-oz. bottle. I think they are yummy and have given numerous ones to post-ops I know with daily coffee habits. However, they are not for everyone. A woman behind me complains that they smell of beef jerky but don’t taste nearly as good.

Lauralyn Bellamy – “The Key to Overcoming Self-Sabotage in Weight Loss and the Rest of Your Life
Lauralyn spent 51 years of her life on diets before having gastric-bypass surgery three years ago. According to her, “Sabotage is a misguided effort to protect yourself.” It may seem that there is nothing to protect oneself from, but the “reptilian brain” saves us from the unknown. Since many obese people cannot imagine themselves at a normal weight with a healthy, normal relationship with food, the brain considers that a danger zone and will sabotage efforts at weight loss.

Diets work for a short time, she says, because they distract us. Obsessing over food journals, counting calories or carbs or whatever, menu-planning, exercising, etc., keeps the brain from realizing what’s happening at first. Once the brain realizes what’s happened, it kicks in survival instincts and sabotages the weight loss.

Life coaching, Lauralyn’s specialty, is about making life-affirming changes. As she says, “This is not about using food as a reward, it’s about learning how to imagine the rest of your life.”

She goes on to say that it’s important to realize that your “sabotage voice loves you” and make it an ally in your efforts. The challenge is that nobody can dismantle his or her own defense mechanism, which is why therapists and life coaches are needed, she said. One example of a strong defense mechanism, she said, is forgetfulness. A third party can help to keep you conscious throughout the day and throughout your life. That's so important, she said, because surgery alone doesn't fix everything. It's not magic; it takes work.

Dr. J. Timothy Katzen – “Plastic Surgery After Weight Loss”
Dr. Katzen’s specialty has been post-weight loss plastic surgery for the past seven years. He’s certified by the American Board of Plastic Surgery and has offices in Beverly Hills, Santa Barbara and Hawaiian Gardens. Any surgeon can call him or herself a plastic surgeon, so it is very important to make sure surgeons are board certified.

Body contouring is the general term for the type of cosmetic surgery needed after drastic weight loss.

Why is it needed?
Weight loss leads to losing fat, shrinking muscles, buckling fascia (connective tissue). The skin attempts to recoil, but age, elasticity and overall health determines how well it can resume a normal shape.

Dr. Katzen explains what he calls the “Lamp Shade Analogy.” When a person gains weight, the body balloons out – body parts become spherical. When weight loss occurs, the body shrinks, leaving the appearance of a deflated balloon.Medically, reconstruction decreases and eliminates the occurrence of rashes, improves self-esteem, improves hygiene (a big issue when dealing with excessive folds of skin) and increases the ability to exercise.

Dr. Katzen suggests gastric-bypass patients consider cosmetic surgery once weight has stabilized, about 10 to 12 months after surgery and when you’re been at the same weight for about three months. Lap-Band patients, he said, should wait about 22 months after surgery.

He believes in doing reconstruction in a certain order: torso (abdomen and trunk), medial thighs, breasts and arms. Face work can be done at any time, he said. He recommends doing the torso first, because it’s the foundation of the body. He also does not believe in doing all of the needed reconstruction in one shot. He says it’s safer to do reconstruction in a series of procedures.

Another thing to remember, Dr. Katzen said, is that reconstructions are shape surgeries not weight surgeries. Patients should not expect to lose mass amounts of weight from cosmetic surgery, though having excess skin removed may give the appearance of major weight loss.

Cosmetic surgery is considered elective and is usually not covered by insurance companies. However, Dr. Katzen explains the necessity of documenting rashes, skin breakdown, back and neck pain and hernias, which help prove to some insurance companies that the reconstruction procedures are medically necessary.

Some terms to know
Panniculectomy: Removes apron of skin and the fat in it. No muscle tightening, no hernia correction. However, this surgery is the one most likely to be covered by insurance companies.

Abdominoplasty (tummy tuck): Removes skin and fat, tightens abdominal muscles, tightens fascia, allows for hernia repair. Incisions on women can vary from a high "french cut" to a low "hip-hugger" cut or anywhere in between. For men, the incision usually follows the underwear line.

Circumferential Body Lift: A continuation of the abdominoplasty incision that goes right around to the back. The procedure not only tightens the tummy but allows for lifting of the outer thighs, removing saddle bags, removing love handles and lifting buttocks. The incision is low in front, trails up over the hip and goes back down in the rear to help the scar be covered by insurance.

Buttock implants: Dr. Katzen says he’s a firm believer in implants to create a rounder back side. He doesn’t believe other procedures last. Saddle bag removal: Sometimes, body lifts don’t fully remove saddle bags and extra work is needed.

Thigh lift: Varying procedures that tighten and remove excess fat and skin from the legs. According to Dr. Katzen, Blue Cross of California no longer covers thigh procedures under any circumstances. He predicts this to be a trend with insurance companies. If you need a thigh lift, now is the time to try for one through your insurance company.

Breast surgeries: Includes augmentation, lift or a combo of both. Incisions can be in the shape of an anchor, T or lollipop. For women, augmentation is often needed. For men, the procedure is more about flattening the region and tightening the skin.

Arms: Minor problems an be treated with liposuction, medium problems can be treated with a lift that has a crescent-shape scar hidden in the armpit, severe problems require an incision from armpit to elbow.Dr. Katzen suggests people who want cosmetic surgery to quit smoking, exercise regularly and take vitamins as soon as possible before surgery.

Dr. David Elliot – “Protect Your Pouch: Maximizing Your ‘Window’ of Opportunity”
Dr. Elliot, a Santa Rosa bariatric surgeon, starts his session with an anatomy lesson of how Roux-En-Y gastric-bypass works. A one-ounce pouch (about the size of a golf ball) is created at the top of the football-sized stomach. The opening that connects the pouch to the intestine is about the size of a dime.

To protect the brand-new pouch, Dr. Elliot recommends the following the first month after surgery:
Slow progression of diet (food intolerances are common)
Hydration, between meals – not during
At mealtime, protein comes first!
Re-learning to eat (use a small plate, eat slowly)

The stoma (openings to and from the pouch) is swollen the first month, which means that dry foods will get stuck (inducing vomiting or gagging). Also, the divided stomach is hyper-sensitive to many foods, such as caffeine and dairy, among other things. He recommends protein supplements for the first three months in an effort to achieve 60 grams a day (my doctor recommends 80).

Common causes of vomiting:
Stomal stenosis or stricture – stoma closes, causing food and water to come up. Fixed by dilation

Eating too fast – most common reason; patient should spend 30 minutes eating

Excess mucus

Stomal ulcers
Bezoars – collections of undigested foodstuffs (think hairball) that have to be removed with an endoscope

One of Dr. Elliot’s key points is that surgery doesn’t equate to absolute success no matter what. Patients must exercise regularly, eat three meals a day (no snacking) that incorporate nutrient-rich foods to ensure their own long-term success.

Protein is the most important nutrient for the gastric-bypass patient. One point that surprised me, though, is that peanut butter is not considered a high-protein food. He said that the protein is too low in comparison to overall calories and fat. Fish and eggs, however, are excellent protein sources that are often well-tolerated by newer post-ops. For vegetarians, tofu, beans and legumes are good choices.

Hunger tends to return about six months after surgery. The pouch capacity increases (3/4 of a cup), the stoma size increases (pouch empties in two hours instead of four), and weight loss slows dramatically. For people who want to continue losing weight after six months, Dr. Elliot recommends avoiding carbs (they cause cravings and cramping that might be confused as hunger), not snacking (remove temptation from home and work), don’t drink with meals and “water loading.” Water loading is drinking a half-glass of water right before meals to dilute the ghrelin (hunger hormone) in the pouch. This helps some patients be satisfied longer and with less food.

One important thing to protect your pouch from is ulceration. Factors that can lead to ulcers include:
Nonsteroidal medicine (ibuprofen, naprosyn, aspirin)

Dr. Elliot recommends giving up alcohol for life because of the danger of ulceration, as well as the high number of calories. On special occasions, he recommends drinking no more than a half glass of wine after a full meal because post-ops are “cheap drunks” because of how fast alcohol is absorbed by the new digestive tract.

Some patients who think they are in menopause find that their menstrual cycles starts back after gastric bypass. This had to do with hormonal imbalances brought about by obesity. For those who want to conceive, he recommends waiting at least one year before getting pregnant.
Most common reasons for regaining weight:· Lack of exercise· Snacking or grazing· Stretching of pouch because of overeating

Long story short, Dr. Elliot says that falling back into old habits is the main reason that people regain the weight they lost during the honeymoon period. Taking advantage of the honeymoon period to learn and create new lifestyle habits is the key to making sure surgery is a successful tool to overcome obesity.

Dr. Paul Cirangle – Will discuss long-term issues that WLS patients need to be aware of forever and the insurance situation in California
Dr. Cirangle’s first topic of discussion was nutritional deficiencies after surgical weight loss.

Malabsorptive procedures (gastric bypass) lead to more long-term nutritional deficiencies than restrictive procedures (Lap-Band). There are varying degrees of malabsoptoion depending on bypass procedure. Duodenal Switch has the highest incidence of deficiencies. RNY is middle of the road.

Malabsorption is why vitamins are such a necessity for bypass patients. Part of the procedure that is gastric bypass actually bypasses the parts of the intestine that absorb vitamins. Dr. Cirangle cites research that shows that patients who didn’t take vitamins regularly in the first two years after surgery not only became deficient later on but also were less likely to be able to correct the deficiency once it occurred. He says the best vitamins are the ones that you’ll take forever.

“If you don’t like the taste, you won’t take it and that makes it a bad vitamin,” he said.

Other reasons patients develop deficiencies is because they had them before surgery and because of the drastically reduced nutrient intake. A scary point Dr. Cirangle made is that gastric-bypass surgery is a procedure that by its nature causes ulcers. He recommends post-ops take some form of acid-reducer daily for the rest of their lives.

Anemia is common and can be caused by anastomotic bleeding (very rare), marginal ulcers, B-12 deficiency and iron deficiency. A third of post-ops will develop it within two years. Supplementing with folate not only helps prevent anemia but also protects your heart, he said.

“Very occasionally, anemia becomes so profound that we have to reverse the procedure,” he said. “That occurs most commonly with the Duodenal Switch.”

Other possible complications that require reversal are protein deficiency and kidney stones. The good news is that he says anemia is 95 percent correctable with supplementation.

The normal human digestive system is so efficient at absorbing calcium that 90 percent of what most people eat is excreted through feces. But for gastric-bypass patients, calcium absorption is difficult because the part of the intestine that absorbs it is bypassed. Dr. Cirangle recommends taking 500 mg at a time (3x a day) with a protein source to improve absorption. He also said that he doesn’t believe that calcium citrate is the only way to go for gastric-bypass patients to absorb calcium.

“To me, the best calcium is the one you like,” he said. “If you like Viactiv, which is calcium carbonate, that’s fine by me.”

Dr. Cirangle mentioned a new procedure on the horizon called a vertical sleeve gastrectomy. It’s a restrictive procedure – no malabsorption – that uses no incisions and is safest for high-risk patients. His practice has done 500 of the procedures, and he said that for those who self-pay, it’s the most affordable option. The other perk is that it’s the safest option for high-risk patients.

Dr. Monica Ganz – “Learning to Think Thin”
Dr. Ganz, who has lost 320 pounds with the help of gastric-bypass surgery, understands the need for the formerly obese to figure out how to think thin. Thinking like a thin person is the key to long-term success, she says. She’s a high-energy speaker who jumps from topic to topic with rapid-fire speed.The first thing Dr. Ganz recommends is to get rid of too-large clothes. The advantage to doing that is that it’s a commitment to “never go back” to your previous size.

Old habits die hard, she says. Every single day is a battle with food demons, but it gets easier with time. The problem with time is that it’s also easier to lapse into old behaviors. Taking pictures each month is a necessary practice. Many post-ops develop body dysmorphic disorder, which means the brain perceives the body to look bigger than it really is. She says it takes the brain a lot longer to catch up with your appearance than it does to lose the weight. According to Dr. Ganz, it can take up to five years for the mind to adjust. Taking measurements regularly is another tool to help combat body dysmorphia.

Be wary of your relationship with the scale
The key to making this a success is it’s a lifestyle. People who use the scale to determine what they will eat that day (treats if they lost weight; depravation if they gained weight) are still on diets, and diets are proven not to work. A scale is only to be used as a tool to guide you; you can’t depend on it as a measure of your self worth.

Getting back to basics
It takes 21 days to form a new habit, but most people give up at 18 days. Get a food scale and measure your portions.· Read labels· Hydration – if you have trouble keeping it down, try Propel, or something similar· Chew your food down to baby-food consistency· Undigested carbohydrates or protein cause gas· Eat slowly – use a timer· Use smaller size items (mini pans, salad plates, baby spoons, etc.)· Sip water all day long until you get 64 ounces to 74 ounces a day· Stay away from fast food (too much of a trigger)

Dr. Ganz recommends eating about 100 grams of protein each day to account for malabsorption. Not all foods have protein that is easily absorbed. For example, she said that eggs have protein that is 99 percent available, where as peanuts are only 49 percent available. On top of that, gastric bypass patients have 25 percent of their nutrients bypassed, meaning they absorb even less. A good rule of thumb to determine whether you need more protein is if you’re tired or have noticed your weigh loss has stalled.

Some aids to help you on your journey· Lactaid or Lactaid milk· Molly McButter to replace butter· Beano to combat gas

After weight loss, many people don’t know how to dress for their new size and shape. Take advantage of personal shopping services at department stores, even if you don’t buy anything. Have your makeup professionally done; go to a salon and have a makeover. Look your best and you will feel your best.

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