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Craving sushi? You likely will not be able to tolerate your favourite sushi rolls because of the rice and seaweed wrap, however there are several other equally satisfying options on every Asian-style restaurant menu to consider. Indulge in an order of tartar or sashimi. These rice-less options are easier to digest. Don’t be afraid to ask if your favourite sushi rolls can be made with a cucumber wrap instead of the traditional seaweed wrap. This is often a ‘low carb’ option on sushi menus. Order a side of edamame beans. These soybeans are not only a good source of protein, but they are also rich in fibre. Try a protein rich Asian soup. Asian-style restaurants often have a traditional soup with eggs, tofu, chicken, and/or shrimp. Prioritize the solid pieces and leave most of the broth behind. Salmon or tuna salad. Most sushi restaurants have a simple green salad with a seared piece of fish and a flavourful salad dressing. Sandwiches & Wraps· Choose a sandwich on toasted bread. If it is a large sandwich, remove the top piece of bread. Great options include: chicken salad, egg salad, tuna salad and deli meats. Wraps are also a good option. Opt for baked chicken rather than crispy chicken. Breakfast egg sandwiches Choose a breakfast wrap or a toasted english muffin sandwich. Skip the bacon and sausage. Salad Almost all restaurants now have a green salad with chicken. Again, opt for grilled chicken instead of crispy chicken. Other high protein options include: taco salads, chickpea salads and bean salads. Chili Whether you choose the vegetarian or meat version, chili packs a lot of protein. They are also very easy to digest making them the perfect option if you have recently transitioned to solid food. Here are some other helpful tips to challenge those old fast food habits: Skip the combo option… yes, even if it’s cheaper! Don’t order a drink. You will be less tempted to drink and eat at the same time if you don’t have a refreshing beverage staring you down during your meal. Eat in the restaurant instead of in the car. If you are driving and eating, food is more likely to block. You can’t be mindful if you are multitasking! Choose foods described as: grilled, baked, sautéed, broiled, steamed, boiled, etc. more often. These cooking methods are lower in calories. Many corner stores and gas stations now have ‘grab and go’ options in their fridges such as sandwiches, salads, protein shakes, yogurt parfaits, etc. Next time you get gas, make a mental note of 3 appropriate meal options you could choose if you were in a pinch. Bon appétit!- Lisa & Monica

First off, I just want to say this very important thing, if you take nothing else away from this article, let it be this- People’s reactions to you are based on their relationship with themselves, not you. Always. Someone who is living at peace with themselves will have no need to harshly criticize, no desire to humiliate, and no feelings of unresolved jealousy. Sadly, once you understand this, you also realize how many people in your life are unhappy with themselves on some level. It makes it a little easier not to take things personally, but I would be lying if I said those things don’t hurt anymore. So how do you deal with friends and family members who are not living at peace with themselves? What practical steps can you take to be at peace with yourself so that you are able to reject those statements and hurtful judgments instead of internalizing them? Here’s the bottom line- You will always have people in your life who do not wish you well, who want to see you fail. If you do not learn to look past them and stay focused on you and your progress, and live at peace with yourself- you will experience re-gain. I love the words from Eleanor Roosevelt, “No one can make you feel inferior without your consent.” 1) Start with yourself- You need to be at peace with yourself. Who you are, what you weigh, your progress level, etc. Easier said than done, I know. But working towards that will allow you to bypass other’s opinions of you because you know who you are and where you’re going. A simple way to begin embracing yourself is positive self-talk. Start by looking into the mirror as often as you can, and saying things to yourself like, “I am a beautiful, peacefully person and I love me.” Say hello to yourself. “Hi Ash, you are a wonderful, beautiful person and I am SO proud of you.” It’s going to feel super painful and may trigger some emotions. Process those as they come, don’t shy away from the feelings that embracing yourself brings. If you need to cry, do so. If you smile, embrace it. Enjoy yourself. Changing that negative narrative in your head that so many of us carry around, is step one. 2) Be honest- When someone says something that’s offensive, it usually comes from one of 2 places: a poor relationship with themselves, or a lack of education. Use your best judgment to determine which it is. Keep in mind, there are a LOT of myths and misinformation surrounding bariatric surgery. Don’t assume people know more than they do. Think back to before you became an expert on Bariatric Surgery. How many questions you had, how many myths you thought were accurate. Seek to educate. But be honest, if someone makes a hurtful comment, let them know. Keep it simple, “Hey, that was uncalled for.” or “Please don’t say things like that to me.” Try to stay calm and in control. 3) Take a break- If you need a break, take one! Go for a walk, get out of the house, go listen to music alone. Don’t feel bad for needing a break. Family time can be stressful, don’t allow others to jeopardize your progress. When you’re stressed and anxious, you’re more prone to overeating which puts you back on that harmful cycle you’re working so hard to stay off of. Give yourself permission to stay home sometimes too, you don’t need to be at every single family gathering. It’s okay to opt out. People may get offended, they may try to make you feel guilty, but remember- it’s not about you. It’s all about how they feel about themselves. Those who are at peace with themselves will support you and do their best to understand where you’re coming from. 4) Stay focused- This is a tough one. Holidays pull our focus in so many directions, it’s easy for us to lose focus on our goals. Be proactive about making plans for yourself for food and exercising during the holidays. Being ahead of the game and staying on top of your plans will make you feel peaceful and accomplished. When you feel this way, your confidence is harder to shake and you will feel more secure. When you’re focused on a goal, it consumes your focus and the other things that pop up to derail you just fade into the background. Stick to your routine, take your supplements, and stay on track. You can do this! 5) Stay connected- Join a support group in-person or online, find an accountability buddy, hire a coach, or grab a friend who will keep you focused without judgment. Someone you can call, text or write to keep them updated so they can provide you with the encouragement you may not be getting from others this season. Having connection fills an emotional need that many try to fill with food. If you’re getting that need met, you won’t be as tempted to eat for comfort. Connection is something we all need, so make it a priority to have someone in your corner this holiday season. Remember, at the end of the day- this season is temporary. All the food, all the family, all the hustle and bustle. The things that can make or break this season. It’s all temporary. You are what you carry into the New Year. Your health journey is what lasts. Keep your sights on the long term. You can do this, I believe in you!

Finding unflavored protein in a single serve packet will allow you to sample a brand without having to buy the larger container first. Single serve packets of whey protein isolate are available online with Bariatric Fusion, Jay Robb and Unjury. Whey protein powder is also found in the bulk bins at Sprouts Farmers Market. You can buy a small amount to taste test. Our patients have also liked the larger containers of unflavored whey protein by brands like Inspire , Isopure (GNC, online) and online (online). Keep in mind, whey protein must be kept under 140 degrees, otherwise, it will curdle. Soy protein isolate is also available. Brands include GNC and brands like NOW Foods and Genisoy, which are available online and some natural foods stores. These will be in larger containers. Sprouts Farmers Market also has soy protein in their bulk bins, so that you can buy a small amount to taste test. Sometimes you can get a sample taste of unflavored protein in stores that sell natural foods, supplements and sports nutrition products. Ask about the return policy if you don’t like the product. There are many other brands of unflavored protein powders on the market. If you have a group of bariatric buddies, perhaps the buddies can buy different brands to try and share. This cuts the cost of taste testing. May your protein status be awesome!

If you’ve made a commitment to change your diet, learn a new exercise routine, start or complete a project, be more assertive, or maybe connect with your intuition on a daily basis, know that you DO have the POWER to follow through with this. Set an intention to connect with and magnify your inner strength and focus. Often when we set out to make changes in our life we start obsessing about it and think way too far into the future which can overwhelm us: then we just say “Oh the heck with this: I’ll never be able to do that huge project or maintain that habit forever, why even bother?” If you notice your thoughts going in that direction slow down, take a deep breath, and get out of your head and into your body. Come back to the present moment. Take another breath. Ask “Is there one simple thing I can do in this moment to honor my commitment?” That might mean just not putting a piece of chocolate in your mouth in this moment: That’s it you did it! And I know you can do that again in the next moment!! Perhaps you will be guided to make a phone call. Pick up the phone and make that call. Or, there might not be anything you need to do in this very moment so relax into the not doing. It is important that you keep yourself surrounded by upbeat positive people and that you raise the vibrations of your surroundings as much as possible. Burn sage, put a crystal on your night stand or desk at work, keep plants and flowers in your environment, listen to uplifting music. Shield yourself from negative energies. Many of you who are drawn to read this are highly intuitive empaths: your are like psychic sponges who absorb the energies of the people near you and your environment. As part of your morning routine surround yourself with a beautiful white light ( or whatever color feels most safe and loving for you). The only thing that can penetrate this light is love and healing energies, no negative energy can pass through this. If you believe in angels, spirit guides, or any other sort of deity invite them to be with you throughout the day guiding you and keeping your thoughts and feelings uplifted and positive. Whenever possible remove yourself from negative situations, decline to engage in gossip or fear based conversations. Anger, negatively, jealousy and fear will only cause you pain. Clear your energy field daily: meditate, spend time in nature barefoot, take baths in epsom sales, move your body, drink plenty of water, etc. Law of Attraction/Source Energy is rooting for you and right by your side giving extra added energy to your thoughts. So keep your thoughts and focus on what you DO want to manifest. See yourself as happy fulfilled and loved….and know that is is so….. Feel gratitude knowing that your life is moving in the direction of your dreams gaining more and more momentum as your willingness to believe and receive all that is being offered to you opens and increases. BELIEVE and RECEIVE!! I'm sending you so much love! Go have an awesome day!! ❤️ Louisa!!

I’m in New Zealand today, where I have been for the past three weeks. It has been a privilege to work with a number of bariatric professionals from different disciplines associated with the Foundations Healthy Living Retreat. During this five-day retreat, a small group of post-operative bariatric patients live together, eat together, exercise together, learn together and share with one another. Various staff members share their expertise about healthy living. Topics include much more than how to eat well and exercise. Participants learn the importance of focusing on personal values in all areas of their lives, discover the importance of positive self-talk, address self-sabotage and learn the importance of living mindfully. Coping skills, communication skills, and boundary setting skills are discussed. The topics of shame and vulnerability are explored, as well. Participants get what all bariatric patients in all corners of the world need following bariatric surgery: the Foundations of Healthy Living. Hmmm… good name for the retreat! What I think as I look around me are the many “non-coincidences” in my immediate surrounding. I do not believe that my being here, halfway around the world, is a coincidence. To begin with, Dr. David Schroeder, a bariatric surgeon, and his wife, Andrea, are, in many ways, absurdly similar in personality to my husband Steve and myself. David and Steve are both kind, intelligent, rational, left-brain thinkers who are mild-mannered and soft-spoken. Andrea and I, on the other hand, while also kind and intelligent, are passionate, passionate and more passionate. Translated, we are thinkers and DO-ers, we are upfront and direct, and are most definitely whatever the opposite of soft-spoken is. Oh, loud. That’s it! Andrea and David are passionate about their work in the bariatric field. They are zealous about the physical health of surgical weight loss patients and are also super passionate about the patients’ psychological health. The Schroeder’s know that the journey of recovering from obesity takes a lifetime and includes the physical and the psychological wellbeing of each person. Andrea created the Foundations of Healthy Living Retreat and they have been hosting the retreats for the past five years. It is definitely not a coincidence that David reached out to me after reading my first book, Eat It Up! Our professional philosophies are very much in sync. My work, with great help from Steve, is all about addressing the psychological needs of patients while their physical needs are being medically managed. David and Andrea, like Steve and myself, dedicate much more than our careers to providing bariatric patients with education and support. We address the WHOLE person, pre-operatively and after weight loss surgery. We put our hearts and souls into the work we do because we are convinced by the feedback our patients provide that they want and need much more than the surgical procedure can provide in order for them to live healthy lives, both physically and psychologically following bariatric surgery. Since meeting in 2011, I have learned a great deal by working with both Andrea and David. The Schroeder’s have twice brought me to New Zealand where I have had the opportunity to learn from and contribute to, the lives and education of their patients and staff. Andrea and David, as well as every person presenting information at the retreat, address bariatric patients from a whole person perspective. Each participant is treated respectfully and compassionately, as a human being who is much more than a bariatric patient. Their emotional support needs are emphasized, as a success following bariatric surgery involves more than dealing with a person’s biological innards. Is it a coincidence that Andrea and David, in New Zealand, know the same things that Steve and I know in the US? We all know and work toward, helping patients and bariatric professionals realize that bariatric patients have tremendous emotional and psychological needs that require attention. Behavior modification by itself is not enough when it comes to sustaining weight loss. If it were, well… wouldn’t more people have kept weight off after diets and bariatric surgery? Is it a coincidence that the bariatric patients I have talked with during individual sessions, along with the participants at the retreats, all from New Zealand, talk about the exact same issues as the bariatric patients I have worked with in the US for the past 15 years? I’m not talking about the physical problems. I’m talking about the lack of self-care this population acknowledges. Not just in their eating and exercise behaviors. These people talk about a great lack of self-value that translates to a lack of proper self-care. The greatest common denominator aside from the physical co-morbidities of the bariatric patients I have spent time with in both countries boils down to this: I don’t believe I’m good enough. That, my friends, is the definition of shame. Our bariatric patients need to heal from the shame that draws them back into unhealthy habits. Healing from shame requires much, much more than a bariatric procedure in an operating room, or “theater,” as they call it in New Zealand. It is not coincidental that bariatric patients across the globe suffer from shame. It is tragic that so few bariatric professionals around the world are willing to provide the full spectrum of care that patients require in order to be able to follow through with behavior modification techniques. Deep shame will eventually extinguish behavior modification efforts. How long before more bariatric professionals get it? How long before more than a handful of patients get the emotional support and psychological care they need after bariatric surgery? How long before we provide a truly comprehensive program to help our patients eliminate shame and establish self-acceptance? The shame belongs to the programs and professionals who do not provide a comprehensive program… because those programs simply aren’t good enough. (Along with the Schroeder’s, I will be offering residential retreats through bariatric centers in the near future. For more information, contact me at connie@conniestapletonphd.com.) I’m grateful for the non-coincidences that have led to meeting Andrea and David Schroeder. I am not surprised to see and hear that the patients in our very distant geographical countries are so very similar. Mostly, I am thrilled to know that there are professionals and patients who know that the Foundations of Healthy Living go way beyond medical care alone! For now, patients can participate in the GAIN While You Lose 10-week program. This is a great way for patients around the country (and the world) to have access to the same topics discussed in the Foundations of Living Retreat. This class includes an hour and a half “lesson,” taught live but available online or via recorded session, followed by weekly homework to make the information applicable to each person’s life. (http://www.conniestapletonphd.com/onlin…/weight-loss-program) Why aren’t we currently doing retreats in the US? Are you, the patients, willing to pay to attend? Are you willing to take the time and spend the money to invest in yourself? Do you value yourself enough to work on your emotional issues? You’ve most likely been willing to pay hundreds to thousands of dollars for weight loss programs, powders, gimmicks and scams. What about actually finding a way to find self-acceptance, a requirement for being able to follow through with behavior modification tools? Patients: there is no shame in having problems. It is tragic to me if you know there are problems, but choose not address them. Please seek the help you need! After all: YOUR HEALTH is YOUR RESPONSIBILITY. THIS DAY. EVERY DAY.

In this space remember the importance of prioritizing good self caretaking, talking more kindly to and about yourself, embracing and feeling your feelings, setting boundaries, declining to engage in gossip or negative chatter, walking away from low energy people and situations, being gentle with yourself, not putting unrealistic demands on your time or energy, and understanding that it’s actually GOOD to be SELFish. Bring to the forefront of your mind your innate knowing of the absolute necessity of nurturing your soul with things like art and music and movement and nature and deep conversations with people you love, respect and admire. Let this Valentine’s Day be a Reminder that you need to Love YOU FIRST. That you need to be your most significant other <3! Live In Love, Louisa

Make a List How can you chase what you want if you have not identified it? How will you know you have found what you are looking for if you did not know you were looking for it? You may have thought about making a list of motivators for weight loss surgery and weight loss. Have you considered making a list of what you want to get from your efforts? Making a list of what you want can help you figure out how to get it. The first article in this series might help you put together a list. It could include some of the following, and any of your own items. More confidence in social settings. Saying “yes” to anything – movies, restaurants, and airplane trips – without thinking about whether you fit in the seat. Staying away from the doctor’s office. More time with family because now you have the energy. Attitude: Gains over Losses It’s all about the attitude. You do lose a lot – besides weight – when you commit to Weight Loss Surgery and the Weight Loss Surgery diet, but you will not be doing yourself any favors if you focus on the losses. It is easy to feel discouraged and feel sorry for yourself if you focus on some of your losses: no more soda, no more free-for-alls at the all-you-can-eat buffets, no more eating whatever, whenever – because you literally cannot stomach it anymore. Cliché as it may sound, you are more likely to succeed when you put a positive spin on it. Also cliché but true: practice makes perfect. You can train yourself to think positively just by practicing. Don’t think about losing dessert at the restaurant; think about gaining the ability to enjoy friends and family without focusing on sugar. Don’t think about giving up your mornings sleeping in because you have to exercise; think about gaining better nights of sleep because you no longer need a CPAP machine and gaining clear-headedness that will carry you through the day. Celebrate! It is human nature to respond to successes. When you are doing well at something, you are likely to continue to do it. In the same way, you are more likely to stick to your Weight Loss Surgery meal plan and exercise program when you realize how well you are doing. Recognize each victory with a celebration. Some of your celebrations could be a tangible reward, such as a massage for hitting a weight goal or a new workout outfit when you meet your goal of hitting the gym 20 times in a month. For other victories, you might be able to give yourself the positive reinforcement you need with a simple sign of recognition, such as placing a gold star on the calendar to mark your difficult but healthy choice to pass up the bread basket in favor of a side salad. Eventually, even giving yourself a physical or mental pat on the back might be enough to remind yourself how good it feels to be moving in the right direction. Put Yourself Out There The gains are yours for the taking, but sometimes, you may have to make an extra effort to take some them. This is especially true with some of the gains having to do with people. Put yourself out there at work or in social settings, and you may get some of the most rewarding gains of weight loss surgery journey. When you show off your new confidence, people will respond to you. Add to that some clothes that you are proud to wear, and you are more likely to get the job and land the business deal. You will find it easier to enjoy the moments with old friends and to make new ones. The weight loss surgery journey has so much to offer, so do not let yourself miss out! Know what you stand to gain and keep your eyes open for opportunities to make those gains, and your weight loss will be only one benefit of the entire journey.

Bigger from Birth…And Then College Hit Michele was always big. She was at the top of her height and weight charts from the time she was an infant. She remembers times in her childhood when she couldn’t or wouldn’t participate because she was so big. She didn’t like physical education or sports, and the other children teased her. Food was a comfort. Michele describes the situation as a vicious cycle. The more kids teased her, the worse she felt. The worse she felt, the more she ate. The more she ate, the more she weighed. The more she weighed, the more she got teased. College was a disaster in terms of her weight. Forget about the freshman 15. What about the freshman 40? And the sophomore 40? Add to that the junior 40, the senior 40, and, for good measure, the super-senior (fifth-year) 67, and you now know how Michele Elbertson got to be 427 pounds at the age of 22 years. A Young Weight Loss Surgery Patient with New Relationships Michele made the decision to get the lap-band on her own. She needed a tool to help her control how much she ate, but understood that it was up to her to control what she ate. She only told her parents about her decision after she was sure about it. They were supportive, and have been since then. Michele has taken full advantage of and responsibility for the band. She has lost 260 pounds – 260 pounds! – in less than four years. As she says, she’s a determined person who will accomplish anything she sets her mind to. Michele began to “eat to live” rather than “live to eat.” As her relationships with food and exercise changed, so did her relationships with some friends. She lost some friends whose relationships centered only on food. She gained many more, though, through her new activities. She says the friends she’s gained through running and fitness far outweigh those she lost by changing her lifestyle. An Athlete Is Born Michele ran her first 5k after losing 100 pounds – when she was still 327 pounds. She was hooked. She loved the training, the atmosphere of the race, and the accomplishment. She has never looked back. Since then, she has run countless other races, including 38 half-marathons, 6 marathons, and a 50-miler ultra-marathon. She has also competed in triathlons. Now at an athletic 159 pounds, Michele has her sights on even greater challenges. In the near future, she wants to run a 100-miler and complete an Ironman. Both are feats that most people wouldn’t even dream of. Marathons, Ultras, and Ironmans Now, not everyone’s a distance runner or triathlete, so to understand Michele’s accomplishments, here are a few facts about these endurance sports. A marathon is 26.2 miles. All marathons are 26.2 miles. An ultra-marathon is anything over 26.2 miles. Michele’s recently completed ultra-marathon was 50 miles, and she is training for a 100-miler. A triathlon includes swimming, biking, and running. An Ironman triathlon consists of a 2.4-mile swim, a 112-mile bike ride, and a 26.2-mile marathon. Fitting It All in Every Day Michele works out 6 days a week. Currently, she’s training for an ulta-marathon and is running 5 days a week and lifting weights 3 times. She also does Zumba classes. She takes a rest day once a week. Michele has built her life to be able to accommodate her training schedule. She recently quit her teaching career to focus instead on helping others achieve their fitness and health goals. She is a personal trainer and group fitness instructor. Working at a gym is pure genius – it leaves her with no excuse not to get her workout in! Eating Like a Bariathlete How do you have energy to train like an athlete and work full-time while losing over 200 pounds in 4 years? Ask Michele. Here’s how she eats and works out in a typical day. 7:00 a.m. breakfast: almonds and yogurt or eggs/romaine lettuce 9:00 a.m. snack: protein bar Workout, such as running, lifting, or group fitness class, such as Zumba or bokwa Noon. lunch: soup or salad, usually the largest meal of the day 2:00 p.m. snack: cheese and crackers or something small, equivalent to 200 calories (may include a fruit or vegetable) 4:00 p.m. snack: hot tea 6:00 p.m. dinner; lean protein, veggie, possibly a carb 7:30 p.m. snack: lemon water/hot tea. The number of calories Michele eats during a day is 1,800 (her resting metabolic rate) plus half of the calories she burns through exercise. So, if she runs 10 miles and burns 1,200 calories in exercise, she’ll eat 1,800 plus 600 calories, or 2,400 calories. She allows herself an occasional treat meal with junk food, but still counts those calories. The Accolades Michele is more than your typical bariatric patient, and she’s been getting the recognition she deserves for her extraordinary achievements. These are a few recent examples. Runner’s World magazine Cover Contest Finalist. Makeover on the Rachel Ray Show. Local feature on 6ABC Action News in Philadelphia. Dealing with Negativity – Don’t Worry About It One of the most striking things about Michele is her drive. She has worked very, very hard to get where she’s at today. She’s lost 60 percent of her body weight through being very disciplined every day. And, she has run marathons. Anyone who has run a marathon can tell you that it is was harder than they had ever imagined. Anyone who hasn’t run a marathon cannot imagine how difficult it is. But with all the publicity, Michele has receive a lot of nasty comments. How is she supposed to react when people slam her? They say she hasn’t accomplished anything, that the band has done it all. In fact, they basically say what a lot of weight loss surgery patients hear all the time from people who don’t know any better. So how does Michele react to negativity? She doesn’t want to respond directly and add “fuel to the fire.” She knows they don’t know anything about her, and she’s probably done more exercise and worked harder than they ever have. So, she just goes about her business. Leading by Example Michele says she hopes her successes and story will give others hope. She describes herself as a “real person” and “very down-to-earth,” and she hopes others will see that they can accomplish what she has. In the future, she would like to travel to seminars as a motivational speaker. In the meantime, we congratulate her on her amazing story and wish her well in her 100-miler this spring!

The 3rd Annual National Obesity Care Week (NOCW), October 29th through November 4th, seeks to ignite a national movement to ensure anyone affected by obesity receives respectful and comprehensive care. [Insert your organization’s name] is proud to join the Campaign, which was founded by The Obesity Society, the Obesity Action Coalition, Strategies to Overcome and Prevent Obesity Alliance and the American Society for Metabolic and Bariatric Surgery. All NOCW supporters recognize the 5 Reasons to Care: Obesity is a serious disease. Weight bias is faced by many. Healthcare providers need to have positive, helpful conversations about weight with their patients Science-based weight management options are available for treatment. We need your help passing the 2017 Treat and Reduce Obesity Act (TROA). Although we must educate people about these 5 reasons to care, we must also address barriers to care, such as weight bias in both society and among the medical community. We need more voices – your voice – to reach our goal of achieving better care. You can join us and take action to change the way that you care about obesity by taking the Take 5 Pledge. The Take 5 Pledge is intended to inspire action by addressing the 5 reasons to care and encourage us to change the way that we care about obesity. More information about National Obesity Care Week and their Take 5 Pledge, including information and resources, is available on www.ObesityCareWeek.org. Mark your calendars, and join us in recognizing National Obesity Care Week, October 29th – November 4th.

I often tell patients, “The surgery does what the surgery does.” What I mean by this is that weight loss surgery almost certainly will affect how much food you can eat, but may do little to change what you eat. Weight loss surgery does not make you suddenly crave healthier and less caloric food. You have to make those choices for yourself. Additionally, while losing weight may make it easier for you to adopt a more active lifestyle, surgery itself will not make you suddenly fall in love with exercise. So making health behavior changes in addition to having surgery remains critical. So what specific health behavior changes have been shown to improve outcome? 1. Document what you eat – Many people strongly dislike writing down what they eat but there is evidence that this helps people after weight loss surgery as it does with non-surgical approaches. The reason is likely that documenting what you eat gives you valuable information about your behavior and allows you to make changes when necessary. Consider that your actual weight is the end product of what you eat, so weighing yourself gives you the results, but not the information necessary to make changes. For many, weighing themselves is a pass-fail exam. Either I’m a good boy or a bad boy. Consider that you can’t actually change your weight…you change what you eat and/or exercise, and that is what helps change your weight. Many people seem to have little or no objection to weighing themselves so why do so many people despise writing down what they eat? Writing down what you eat is the truth teller. It forces you to acknowledge what you are doing. To avoid seeing the truth, you can either change what you eat or stop writing it down. Unfortunately, many people choose the latter. The good news is that in the smartphone era, there are literally dozens of apps and other technological devices that can make documenting your food and activity level extremely easy. If you do a little research you can find one that is right for you. 2. Exercise – You probably saw this one coming as well because it makes sense. Regular exercise is a way of burning calories and losing weight that does not involve changing what you eat. Given how difficult it is to lose weight and keep it off, it would be silly not to take advantage of one of the few methods known to work. Ironically, it might not work the way you would expect. Many people who lose weight through exercise notice that it helps them not just by burning off calories, but also by affecting their food choices. In other words, when you discover how difficult it is to burn off 250 calories on a treadmill, you may think twice before having that chocolate bar afterwards. Not everyone finds this effect, but for those who do, it can make a big difference. When deciding what form of exercise to do, consider that you don’t need to become an Olympiad or a marathon runner. Many of the positive effects of exercise have been documented with just walking 30 minutes 3-4 times per week. If rigorous exercise is enjoyable for you, that’s great. But any time spent engaged in activity is beneficial...especially if you would otherwise be sitting on the couch watching all of those tempting food advertisements on television! 3. Stress Reduction – An increasing amount of research has documented a relationship between stress and weight gain. The obvious connection is that many people use food as a means of comforting themselves from distress, commonly called “emotional eating.” An interesting new discovery is that is that some people who report high levels of stress gain weight even when their calorie intake is unchanged. How is that possible? There is the suggestion that stress hormones and other chemicals may affect how our body metabolizes food and stores food. So even if you’re eating the same foods and the same number of calories, what your body does with those calories can vary. If you’re going to be successful in reducing stress, you need to begin by discovering what “pushes your buttons” and take steps to change. One first step could be to document the things that you find to be stressful. Sometimes just writing down your problems makes them less frightening now that they’re just words on a page. For other people, writing their sources of stress naturally leads them to write what they might do about them. Another good idea is to investigate some simple stress management techniques. Many refer to them as relaxation or meditation exercises. As discussed earlier, there are a number of excellent smartphone apps and other technology-based methods of relaxation that you can explore. No one is better than the rest so just find one that works for you and begin to incorporate relaxation/meditation into your daily routine. If reducing your stress requires more than practicing relaxation techniques, consider speaking to a psychologist or other mental health professional to get the help you need. 4. Get some sleep – Here’s another suggestion that you’ve probably seen in the media recently. There is growing consensus of an obesity-sleep connection. Like exercise, the benefits of sleep are more than meets the eye. The obvious connection is that if you’re up longer, you become hungrier and are likely to eat late at night. This interpretation is not wrong, however, new research suggests that people who get 7 or more hours of sleep tend to maintain lower weights even when people with fewer hours of sleep consume the same amount of calories. How is that possible? Again, it’s not just how many calories we eat…but what our bodies do with those calories. Unfortunately, an increasing number of people are so busy between their work and social lives (not to mention all those tempting television shows) that sleep is not a priority. Just know that making sleep the last priority comes at a cost. Consider how we train children to sleep. We create a nighttime ritual to ease kids to bed. There’s dinner, wind down time, then bath time, maybe reading a story or two in bed, and then lights out. Many adults however have a terrible routine. Eat a big dinner at 9pm, catch up on emails and pay bills, watch television for an hour or so and then fall asleep on the couch and stumble into bed at 2AM only to have to wake up three or four hours later. Try to change your sleep habits by changing your nighttime ritual. Eat an earlier dinner. Try to pay bills and check your emails at another time. Use the evening as wind down time. Rather than fall asleep on the couch, watch a set amount of television or Internet time and then turn it off and “put yourself to bed.” Begin by trying to go into bed a half-hour early every night for a week and see how you feel. If you notice some improvements in your level of energy, mood, appetite or other factors, see if you can make it permanent. 5. Join a Support Group – Some research has demonstrated that patients who participate in support groups lose and maintain more weight than those who don’t. Of course it may depend on the content of the group and who attends, but adding a social element to your weight loss and weight maintenance goals seems to help. This may relate to the accountability factor discussed earlier. If “we’re all in it together,” there may be more of a commitment to stick to your goals to help out the group. Or perhaps it motivates you not to be the one group member who is falling behind. Either way, participating in support groups seems to have benefits both in terms of weight loss as well as emotional well being after surgery. There are other suggestions of course, such as improving your diet by reducing carbohydrates in favor of lean protein and a more plant-based diet. However, for many people, changing their diet can push all of those emotional “diet” buttons; so before you make those changes (or in addition to making those changes), strongly consider some of the changes recommended above. There is evidence that the benefits are additive. For example, many people find that when they exercise, they sleep better and in turn these changes help them manage stress better. The key is to acknowledge whether or not some of the factors above are problem areas for you and to begin making small changes. Sometimes small changes can lead to big results!