Alex Brecher

Mark your calendar for October 30 to November 5. That’s when National Obesity Care Week is happening this year. As its name suggests, National Obesity Care Week is a campaign to improve care for obesity, since many obese patients do not receive the care they want or even the care they are entitled to. You may be one of them. National Obesity Care Week Background Fighting obesity successfully includes improving obesity treatment as part of regular healthcare. That sounds promising, but it has not yet panned out. To combat this, The Obesity Society (TOS), the Obesity Action Coalition (OAC), Strategies to Overcome and Prevent (STOP) Obesity Alliance, and the American Society for Metabolic and Bariatric Surgery (ASMBS) developed National Obesity Care Week. The event is aimed at raising awareness among patients, providers, and policy makers, and improving the quality of care obese patients receive. The first National Obesity Care Week happened in 2015. This year, the event runs from October 30 to November 5. Shortfalls in Obesity Care It would make sense for doctors to help their patients with weight management. But, as you may well know, many doctors do not. Primary care and other doctors may not set aside time during regular appointments to discuss your weight. If they do, they may not talk about strategies for managing it. This can be because there is not enough time, or they do not know much about the topic. Even if doctors do approach the subject of weight management with you, they may not have all the information they need, or they may not deliver it well. Doctors do not usually get much nutrition education, so how can they be expected to pass it on to you? They may also be guilty of “blaming the patient” and writing you off as a lost cause. After all, they may figure, it’s your fault you’re overweight, and it’s a choice you’ve made. They have no idea how ridiculous this assessment is! Even when doctors are genuinely interested in helping you, they may not have the resources at their fingertips. They may not know where to find meal planning and exercise materials to help you. They may not know which dietitians are in your health plan. They may not know when it’s time to consider weight loss surgery, or have a network of bariatric surgeons to refer you to. And finally, there’s the issue of money. Does your insurance cover obesity treatment, appointments with dietitians for meal planning and other support, and any mental health counseling that could address underlying causes of obesity? Does your insurance cover weight loss surgery at all, and is it the type you want to get? Probably not! Making Progress, Slowly Most of us in the weight loss surgery community have known that obesity is a disease for years. In 2013, the American Medical Association (AMA) finally made it official. Their reasoning was that obesity is so strongly linked to the development of other chronic diseases that it needs to be treated medically. Naming obesity as a disease increased awareness. Then, American Heart Association (AHA), The Obesity Society (TOS), and American College of Cardiology (ACC) published guidelines for treating obesity starting with the primary care doctor. They suggest a role of the doctor in assessing obesity and providing dietary counseling for the obese patient, along with monitoring weight and willingness to comply at each appointment. They also suggest considering bariatric surgery when other methods fail. But you may still run across many challenges to obesity care! Doctors are ignorant or insensitive. It’s too expensive. You do not know your options. Make the Most of Each Appointment Your doctor may not take the lead, but you can. Come to your next appointment with a list of questions and talking points. These can get a conversation started and help you take action. Let the doctor know what you are doing to lose weight, such as watching your diet or adding in some exercise. Show your doctor how your weight has changed over time. Bring in a few typical days’ worth of food logs and ask for comments. Explain to your doctor why you believe you are having trouble losing weight, and ask for help addressing those issues. Ask your doctor for a referral to a nutritionist or dietitian. If you are eligible and possibly interested in weight loss surgery, ask your doctor for a referral to a bariatric surgeon. Know Your Healthcare Plan Cost should not be a factor in your healthcare, but it is. Things are getting better, though. The Affordable Care Act requires all private insurance plans to cover screening and intensive behavioral counseling for obesity. However, in practice, counseling can range from telephone consults to in-person comprehensive programs. Weight loss surgery is covered only some states. It is becoming more commonplace, and your options are generally increasing. While only more established surgeries such as the adjustable gastric band and gastric bypass might have been likely to be covered previously, now some plans include the country’s most popular option, the vertical gastric sleeve (sleeve gastrectomy). You can do best for yourself by becoming familiar with your healthcare plan and exactly what it covers. So, as National Obesity Week happens, take some time to think about your own obesity care. Is it adequate? What is it lacking? How can you make a difference by being your own advocate and learning all you can about your options? Getting the care you need can be a fight, but it is a necessary and worthwhile one!

If you have ever felt that obesity care is not as good as it could be, now is your chance to make a difference! The Obesity Society (TOS), the Obesity Action Coalition (OAC), Strategies to Overcome and Prevent (STOP) Obesity Alliance, and the American Society for Metabolic and Bariatric Surgery (ASMBS) are sponsoring National Obesity Care Week this October 30 through November 5, and you can be involved! Join BariatricPal and other weight loss surgery and anti-obesity advocates this year as we fight obesity through better healthcare. One initiative you can take part in is TAKE5. This challenge lets healthcare providers work with patients to fight obesity and improve health. Here are the 5 parts to the challenge! They are directed towards doctors, but patients can play a major role, too. Take 5 minutes to learn how to talk obesity with your patients, family or friends. Good communication is essential for a successful patient-provider relationship, but not all doctors talk to their patients about obesity. The topic can be embarrassing, or doctors may not know what to say, or they may assume the patient “is choosing” to be overweight and therefore does not need or want to talk about it. Wrong! If you’re a patient, you can start the conversation whenever you’re ready. If you’re a provider, it may be worth your while to take a few minutes to learn how to talk obesity with your patients. Here are a few ways. Ask your colleagues how they start a conversation with their overweight patients. They may have some good opening lines that relieve tension and do not sound accusatory. Identify a few patients who have successfully lost weight. Ask them how they did it, what role their healthcare providers played, and what they liked and did not like about how their doctors handled the situation. Remind yourself that obesity is a disease. You would not treat a cancer patient as though cancer were their fault; do not treat obese patients as though they chose to be obese. Learn to be sensitive. Talk to a few overweight patients to ask them about their preferences for how doctors approach them. Remember that each patient is an individual. Any obesity treatment that will be successful needs to fit into their lifestyle. Their obesity occurs in the context of their lives, their food habits, and their family and friends. Ask 5 questions to start a conversation. Patient or provider, you can get the convo started by asking some questions. Patient: Here is how I usually eat in a day. Can you make any suggestions to help me lose weight? My knees and back have been hurting, and I think it may be related to my weight. Do you have any suggestions for me? What kind of weight loss counseling can you refer me to? I have been trying to lose weight for years, and it hasn’t worked. Can you please explain how weight loss surgery might help? What are the options for weight loss surgery, and where can I go for more information? Provider: Your BMI is in the obese range. How do you feel about that? I noticed that you gained/lost weight since I saw you last. Why do you think that happened, and how do you feel about it? Do you know some of the health effects of being overweight, and do they make you want to lose weight? What have been some of the reasons you feel you have not been able to lose as much weight as you wanted? What do you feel I can do to help you lose weight? Know 5 reasons to address obesity. There are unlimited reasons to address obesity, but healthcare provider or patient, having them in mind can keep them on your priority list. Here are five out of many possible reasons. It kills. Obesity raises the risk for leading causes of death including certain cancers, heart disease, stroke, and diabetes. It hurts. Knee pain, hip pain, low back pain, and arthritis are just some of the painful conditions that can make obese patients suffer every day. It’s embarrassing. Obese individuals can go through life feeling the stigma of their disease. Others often judge them unfairly based on their appearance. It’s expensive. How much do patients and providers spend on medications and obesity-related treatments? Employers even discriminate based on obesity, even though it is technically illegal. It’s limiting. Obesity can make patients miss out on family vacations, and even trips to the movies or a restaurant if they cannot fit in the seat. It’s treatable – so there is no reason to ignore it! Any amount of weight from a little to the amount expected with weight loss surgery can improve health, life expectancy, quality of life, and self-confidence. Engage in 5 reasons to inspire action. What’s in it for you? Why should you inspire action? What are the benefits of improving obesity care? Provider or patient, being healthy lowers costs – think about money saved on prescription medications, doctor’s appointments, and treatment for diabetes complications, strokes, and heart attacks. Better care leads to better weight loss. Improving obesity care can lead to better overall care when patients and providers form a partnership. Better coverage for obesity care increases access so patients can be sure they and their families will get the care they need and deserve. Patient or provider, you can win when other providers get the message and work together to solve obesity. So spread the word! Pass this challenge on to five of your friends or colleagues. Why stop at five, and why stop at friends or colleagues? Tell everyone you know about National Obesity Care Week and how they can help raise awareness to improve obesity care. So, are you up to the challenge? Healthcare provider, patient, or obesity care advocate, you can be part of it this year. Share in the comments how you’re spreading the word about obesity care and working to improve care for everyone!

When I had surgery in 2003 I didn't tell a soul since I knew that everyone (friend's and family!) would try to talk me out of my decision to move forward. I felt guilty about hiding this big secret from them. It was the BEST decision I ever made! Years later most of my family and friend's are pro-WLS since they've seen how it positively changed my life.

Looking into weight loss surgery and deciding to get it is exciting. You are probably happy about the prospect of getting your weight under control for the first time in years, if not ever, and you are probably eager to make progress your journey. Unfortunately, you may find that some of your family members and closest friends do not share your enthusiasm for Weight Loss Surgery. Instead of sharing your excitement and promising their support, they may express concern about your decision. They may even “forbid” you to get Weight Loss Surgery. How do you deal with family members and friends who are against Weight Loss Surgery? Bariatric surgery is known for being tough on relationships, but there are some things you can do to try to win them over. At the very least, you can go forward with your Weight Loss Surgery plans without letting family members drag you down. Why Does It Matter? Support during your Weight Loss Surgery journey can help you succeed. It is motivating to know that the people who love you are on your side. Through the long days of diet restrictions and dramatic lifestyle changes, your journey will be easier if your family members and friends pitch in however they can, whether with verbal encouragement or concrete changes such as avoiding eating off-limits foods in front of you. Still, it is important to remember that you CAN succeed, whether or not you get the support you hope for. Get to the Heart of the Matter First, make sure you know why they are against your weight loss surgery. It is often because they are afraid for your safety. They may know people – or know people who know people who know people – who had complications from Weight Loss Surgery. You can talk to them about the real risks of surgery – using statistics rather than hearsay – compared to the risks of remaining overweight. Still, do not assume that your safety is why they are negative about your decision. It is important to let them express their concerns and to address them directly. These are some other common reasons why your family and friends might have a negative gut reaction to your exciting news. They may be worried that you won’t be able to stick to the Weight Loss Surgery diet, and that you’ll be disappointed with the results. They may think you don’t need it. A lot of family members have trouble seeing how overweight you are, and understanding how much it interferes with your life and health. They may feel insulted. Parents especially may feel as though they have failed if they see you, their child, opt for surgery. They may feel threatened. Your significant other, for example, may be comfortable in the relationship you have had for years, and may worry that the way you feel about him/her will change as you lose weight. They may not know what it means for them. Friends may worry that you won’t want to hang out with them anymore, especially if your time together tends to revolve around food or if they think of you as their dependable “fat friend.” Whatever the true concern is, address it directly. Reassure your friends and family that you are doing this for you, and that you will not become a different person. Offer Them a Role Some friends and family members may feel overwhelmed by your news of Weight Loss Surgery, and that can lead to their negative response. Surprisingly, offering them ways to be more involved in the experience can actually help change their minds. They may feel better about your WLS once you tell them the details about the prep, procedure, and diet, and may even be grateful if you let them know specifically what they can do to help. Address Meal Times Directly Food is central to relationships at home and in social settings, so it is understandable if your loved ones are worried about how your upcoming Weight Loss Surgery will affect the time you spend together. If you think this may be a concern, discuss meals at home and in restaurants with your friends and family. Let them know that you will still be present at the table and interested in being good company, even if you are not eating as much as them or ordering the exact foods that they are. If you are comfortable with the situation, they are more likely to be. Agree to Disagree In most cases, family members mean well. It may be hard to remember or see in the heat of the moment, but they often do genuinely want the very best for you. If you have already tried your hardest to convince them to support your Weight Loss Surgery decision and they are not ready to do so, your next hope is to keep them as an ally in other aspects of your life. Hopefully, you and they can agree to disagree about your Weight Loss Surgery. You can let them know that you respect their opinion and will not be pressuring them to support your WLS. In exchange, you can ask them to continue to be your friend regardless of whether you are a bariatric surgery patient. Be Patient Sometimes, it just takes time. Your own Weight Loss Surgery success may be the best argument for why your loved ones should support you. It may take weeks, months, or a year, but they may come around as they see how happy you are, and as they realize how much they miss you. Bariatric surgery is a lot easier when everyone you love supports your decision, but that’s not always the case. Don’t let resistance from family members and friends get you down, though. They’re probably trying to act in your best interest, and in most cases, you can still get Weight Loss Surgery while keeping strong relationships with them.

@@rydersmama, congratulations on developing all of these new problems! And thanks for this great thread. Yes, being cold without 100 lbs of fat to insulate is definitely a problem that didn’t exist before weight loss surgery! It’s nice that I can fit into the extra layers of clothing that I need, though! Another one is the annoyance of people telling me that I don’t need to… “You don’t need to watch what you eat.” “You don’t need to skip dessert.” “You don’t need to work out so much.” Well, yes, actually, I DO need to! That’s how I am able to maintain my weight loss! It is so flattering that people see me as someone without a weight problem, but it is annoying when they think I can maintain my weight without any effort – almost nobody can, even most people who have never been overweight work really hard to prevent weight gain! All these “skinny people problems” are such beautiful reminders of how far I have come, and I wouldn’t trade them for anything.

@Elizabeth Anderson RD, Thanks for being the voice of reason on this issue! It kills me when WLS patients avoid all fruit, no holds barred, because they look only at its sugar content. I realize that some gastric bypass patients especially might get dumping syndrome with too much of certain kinds of fruit, but most WLS patients can safely eat fruit and benefit from it. Fruit is like any other food. It needs to be eaten in moderation, and as part of a healthy meal plan. For those who are more prone to blood sugar spikes, it’s probably better eaten with some Protein. And it’s never healthy to eat unlimited amounts of anything! Fruit has so many health benefits that there’s no way it’s “like eating candy!” It’s packed with Fiber and other nutrients, including, as you mentioned, various antioxidants. Research links it to lower risk for heart disease, diabetes, and some cancers, not to mention…lower body weight! That’s not quite the case with candy! Thanks for the article!

When you decide to get weight loss surgery, you join a unique community. Bariatric patients have a lot in common. We’ve struggled with weight for years. We’ve been unable to keep the weight off with regular diets and exercise. And now, we’re bound to each other by a special bond: the weight loss surgery. Weight loss surgery is for life. The journey isn’t easy, but I believe that the best way to make it work is to take the best of both worlds. Recognize that we are bound to each other through our weight loss surgery, but don’t let that special tie isolate you from everyone who has not had weight loss surgery. Instead, recognizing the similarities in all of our lives can make our own challenges easier to overcome. These are some of the things we all share, weight loss surgery or not. For each, there are some unique aspects for bariatric patients, but also parallels with everyone else. We all have a daily struggle. If you’re overweight, there’s a good chance you’ve looked enviously at people who are at a “normal” weight. You see them walking down the street, maybe wearing a cute outfit that you can only dream of wearing, and wish you had it as easy as they did. You’re jealous because your own weight problem is visible to the world. But we all have our own struggles, and you don’t know what is going on in that person’s life. They may face abuse, struggle to pay the bills, suffer from a chronic disease, care for a sick child at home, or work at a job they hate. Just as you struggle every day to eat right and exercise, they may struggle every day to wake up and face their own challenges. Rather than envy them, think of other people as inspiration to get through your day. We are all in this together, doing the best we can with what we have. We all keep certain things from our bosses. Many bariatric patients are hesitant to tell our bosses about our surgery. We may fear judgment or retribution. We may just want to keep our personal lives private. It’s not always that easy to keep quiet about Weight Loss Surgery, since we need to eat differently and our appearances change as the weight comes off. There may even be times when we need to leave work because we feel sick or have doctor’s appointments. But guess what – nobody tells their boss everything about their personal lives. I am certain that all of your coworkers have their own secrets from your boss. Looking just at alcohol abuse, an estimated 15% of the workforce has come to work after drinking or with a hangover! Add to that secrets such as playing hooky to see a sports match, searching for a new job, or living out of a camper to save money, and you can bet that every employee has their own personal issues that they don’t want to publicize to the boss. We all want to be there for our families (or worry about our futures). One of the most compelling reasons to get weight loss surgery is to be there. We want to be alive and be healthy for as many years as possible to support our families and get to enjoy them. With obesity, the pressure to improve health is real and personal, since we may already have our own health problems or have seen family members struggle with or die from conditions such as heart disease or diabetes. But everyone worries about the future. They may worry about their job security, about having enough money for rent and to put the kids through college, and – yes, it’s true – about their health and weight. We’re all short on time. Weight loss surgery success is time-consuming, from meal planning and grocery shopping to food prep and measurement, not to mention working out. It takes some sacrifice to get in all those healthy behaviors, especially before they become habits. But everyone is short on time. We’re all busy with work, school, and family obligations. And that includes diet and exercise commitments, even for people who don’t look like they need to be careful. In fact, the people who are most dedicated to their health are the ones who are best at prioritizing their lives, and making the necessary sacrifices to clear the time to work out and eat right. We can all use a helping hand. Hopefully, this article has shown that we’re all in this together. We can all use a helping hand. Within the bariatric community, resources like BariatricPal can give us the chance to ask questions and give advice. Outside, try to remember that giving someone a smile or encouraging word can mean a lot, and possibly make someone’s day a lot easier.

@Dr. Adeyeri, Thanks for the reminder that the physical changes from surgery only take you so far, and your mind has to handle the rest. We’re told that WLS success is a long-term proposition and it depends our own choices, but don’t always realize that that means changing our mindset. It sounds like you have a good idea explaining to patients that the surgery is only a small piece of the puzzle. It may give a patient the potential to control weight, but that’s all it does. The majority of long-term success and happiness depends on changes in mindset. Thanks also for the great advice on ways to change the mindset. I love your suggestion to make sure you’re improving your quality of life in all kinds of ways as you lose weight, so that the weight loss journey isn’t strictly about weight loss per se, but about making life great. It is all too easy to focus so completely on weight loss that we don’t make the changes needed to enjoy life more, or we don’t realize that now the potential is there to enjoy life more! Thanks for the insights and tips!

@Elizabeth Anderson RD, Thanks for this article! It is so important to get bloodwork done regularly, and so easy to overlook or conveniently forget. A lot of us might naturally think about Iron deficiency anemia as an example and figure all nutrient deficiencies are similar: that you’ll feel the symptoms (such as fatigue from iron deficiency), and that you can reverse them when you start to take your supplement. But that’s not always true. As you said, some complications from deficiencies are irreversible. You’ll never be able to gain back all of your bone mass if you’re low in Calcium for a long time. You can’t overcome certain types of nerve damage from Vitamin B12 deficiency. Also, it’s important to remember that you won’t always see and feel symptoms until it’s too late. For example, you won’t know that your Vitamin D is too low even though you could be losing bone mass. Or women may not have any idea that they’re low in folate until it comes up in a pregnancy screening. Another reason to get bloodwork done is that you can actually get too much of certain Vitamins and minerals. B vitamins are generally safe, but you don’t want to take high amounts of iron for too long without getting your blood levels tested because iron overload can lead to liver problems. Thanks for the article! Oh, and one other reminder: even if you have a whole long laundry list of nutrients to test and you need to fill a bunch of vials of blood, you still only need to go to the lab and get your arm pricked once!

@Elizabeth Anderson RD, Thanks for this great article! It addresses something very important: what happens after the honeymoon when some of the doubts can creep back in? You have hit on some great points. The questions of “Why me?” and “Why is it easier for everyone else?” can be so destructive. It doesn’t matter why me, and it doesn’t matter whether it’s hard or easy for everyone else (by the way – it’s probably hard for everyone else! – the WLS patient may just may not realize it!). What matters is what you do about it. You also make a good point about recognizing and believing that this time is different, that this time you have the tools to succeed whereas before you didn’t. Even though this can be hard to remember and feel sometimes, since the journey never actually gets easy, it is true, and we need to believe it and act on it – that we can do this. Thanks for the article.

Ahhh…goal weight! It’s something you’ve wanted for years. You went through the pre-op diet, weight loss surgery, and the recovery period. You’ve worked harder than most people can imagine in order to get to goal weight. Now, all you have to do it keep the weight off. Well, you know that’s easier said than done, but this two-part series offers a little help. Part 1 talked about what you can do if you hate counting calories, and how to develop a diet pattern that can work for you for life. Part 2 will cover making up for lower calorie burn and staying motivated even when the scale is not going down. Here goes! I Don’t Burn as Many Calories. The more you lose, the less you can eat if you want to keep losing or keep the weight off. There are a couple of reasons for this unfortunate fact. First, your metabolism slows as you lose weight as a response to the dieting. Your body compensates for your low-calorie consumption by conserving energy – which translates to burning fewer calories. A bigger factor is your lower body weight. The less you weigh, the less you burn at rest and while exercising. Take a 30-year-old 250-lb woman with a height of 5’4”, for example. She burns about 1900 calories per day at rest. She burns about another 450 calories for every hour she walks. So, she can lose about a pound a week if she eats about 1,800 calories per day. Take this same woman at 140 pounds. She might need only 1,500 calories per day at rest, and burn 250 calories while walking for an hour. If she walks for an hour a day, she might even gain weight eating 1,800 calories per day. So what can you do to combat this? Being aware is a big step. Know that you may not need as many calories as you used to need. You can cut out calories the way you have been: by taking smaller portions, and by choosing healthy foods and lower-calorie versions of normally high-calorie foods: think of a plate of zucchini noodles (“zoodles”) instead of a plate of pasta, for example. You can also be more active to burn more calories. While an hour’s walk may have been a good workout for you while you were at your high weight, you might be in better shape now, and able to work a little harder. You might be able to throw in a little jogging, or try aerobics or kickboxing or Zumba, to burn more calories in that same hour. Build a little muscle with some strength training, and your calorie burn will be boosted round the clock. I’m Not Motivated. Lack of motivation is one of the biggest barriers to keeping the weight off. Preventing regain takes a lot of work, so you need to be motivated. But how can you stay motivated when one of the strongest motivators – the dropping number on the scale – isn’t there anymore? The first thing you can do is change your attitude. From the time you had WLS to the time you hit goal weight, your job was to lose weight. You had a victory every time your weight dropped, and that was exciting. Now, your job is to maintain your weight. You have a victory every time you step on the scale and your weight is the same. That is exciting, too – hopefully, exciting enough to keep you motivated to do the right thing as you make your eating and exercise choices throughout the day. Most of the motivators that you used when losing weight are probably still there. You may just have to search a little harder to remember them. You want to be healthy. You want to be proud of yourself. You want to be around to support your family and to watch them grow. You want to be healthy. You want to shop in regular stores. Remind yourself of your reasons for wanting WLS, and remind yourself how hard you worked to get here. It’s something not everyone can do, but you did it! I Got off Track. So does everyone. Let it get you down, and you can regain a lot of weight very fast. Take care of it and use it as a learning experience, and it can only make you stronger. Figure out what got you off track, and do your best to fix the habit. Maybe it’s drinking your calories, choosing slider foods, munching throughout the day, or using food instead of the gym as your emotional outlet. Whatever it is, fix it, forgive yourself, and keep going! If you’re really not sure what went wrong, go back to the basics of your post-op solid foods diet. Figuring out your strategies can help you keep the weight off for good. Preventing regain is a lifelong endeavor. You may need to work on it daily, but the payoff can be worthwhile. You worked awfully hard to get WLS and lose the weight – don’t you want to keep it off?

Weight loss surgery is supposed to be the final answer to obesity. Ideally, you use your sleeve, band or pouch as a tool to help you lose weight, and that tool continues to keep you in check as you maintain goal weight. But that’s not always the case. Many Weight Loss Surgery patients find that losing weight is easier than maintaining weight loss. You may already have some hint of that if you were a long-time yo-yo dieter before surgery. So why is it so hard to keep the weight off, and what can you do about it? It can be harder to keep the weight off than lose it in the first place because: You might gradually be less strict with your food choices as the occasional treat becomes more frequent and bigger. Your restriction may not feel as, well, restrictive as it did right after surgery. Your metabolism is slower and you don’t need as many calories as you did before. You don’t have the motivation that comes from seeing the scale go down as a reward for your good eating habits. But a little challenge doesn’t have to get you down! After all, you’re a WLS patient, and you’re in it for the long haul! Here are some things to think about as you are losing weight, approaching goal weight, or even working on maintaining your goal weight. This is just Part 1 of the two-part series, so stay tuned for Part 2! I Hate Counting Calories! Yes, logging your food can be tedious. Some people even find that counting calories makes them anxious or causes them to fixate on food. Maybe immediately post-op you could skip the calorie counting and still lose weight because you had so much restriction. Maybe, in the beginning, you forced yourself to log foods for a few weeks or months. What if, when you’re at or near goal weight, you can’t face the thought of counting calories? You still have a few options that can work. Go back to the meal plan you got from your surgeon or nutritionist and stick to it. If it says ½ cup of oatmeal, it doesn’t matter whether you know how many calories that half-cup contains. You can be certain that if you follow the plan, your total daily calories will add up to the amount in the plan. Log once a week. This can help you stay on track as you make sure your portion sizes are still working out for you and you are choosing the low-calorie, high-protein foods you think you are. Focus on another nutrient, such as protein. If you hit your target grams of protein, stick to small portions, and make sure all of your protein and other foods are the nutritious ones you’re supposed to be eating – think lean proteins, vegetables, and healthy fats, for starters – you have a good start towards eating the way you should. Carbs Are the Devil! Maybe it’s carbs, maybe it’s sugar, maybe it’s pizza, or tacos, or ice cream that you avoid in your weight loss efforts. Whatever it is, there’s a good chance you’re trying to avoid it as you lose weight. Weight loss surgery patients can be tempted to go low-carb, paleo, or sugar-free. That’s fine, as long as you can keep it up long-term. If you can’t, you’re setting yourself up for a rough time. What happens when you hit goal weight and you flip a mental switch in your head? What if you go from low-carb to letting cookies, bread, and pasta back into your diet? What if you go off paleo and find all sorts of processed foods that are delicious and convenient? What happens next time you come face to face with an order of chicken wings and dipping sauce for the table? You may be better off planning for a diet that will work long term. While you are still losing weight or while you are early in the maintenance phase, take inventory of your feelings. Be honest about what you can and cannot live without, and develop a plan to address it. Then practice! These are some possible ways to approach your food fears. Think “healthy, portion-controlled carb” instead of “low-carb.” Aim to get in healthy carbs such as oatmeal, lentils, fruit, sweet potatoes, and yogurt rather than avoiding all carbs. Consider the good and bad of the paleo diet. While the guidelines to avoid processed foods and refined sugars can’t hurt, it really necessary to avoid nutrient powerhouses such as beans (think: protein, fiber, and potassium)? And is it really possible to avoid all processed foods for the rest of your life? What happens if you run short on time? A good strategy may be to get in the habit of reading labels so you develop your ability to choose healthy (or at least, “healthier”) packaged meal helpers. Make up your mind about trigger foods. Are you the type who can be satisfied with one potato chip when you get a craving? Or are you best off avoiding the chips altogether? Is there a similar substitute, such as kale chips, that can work for you? If you’re not sure, experiment so you know how best to handle cravings. Maintenance has its share of challenges, but you can overcome them to be able to experience all the joys of hitting that goal weight you dreamed about for so long. Just like you did when you were getting ready for weight loss surgery and losing weight, you can take a carefully planned approach to maintenance that considers your own preferences. Stay tuned to Part 2 of the two-part series!

@OKCPirate and @MrsSugarBabe, I agree that there are many ways to describe “obesity,” and various descriptors have various connotations associated with them. The American Medical Association recognizes obesity as a disease.

Connie, Thanks for this great article! I love the way that, for each of the causes, you explain the implications for patients and the implications for each. It is so important for patients to take responsibility where possible, and understand and forgive themselves for the external factors that they cannot change. For doctors, it is so important to work with patients and encourage them to make lifestyle changes as necessary, but also to avoid blaming patients for things that aren’t their fault. I think it is also worth mentioning that feeling sorry for yourself for whatever unlucky genes you got doesn’t help. I always think about metabolism and how some people have much faster ones than others. While it may seem (and be) unfair that John Doe gets to eat 500 calories a day more than you, don’t try to keep up with John Doe and rationalize it by saying, “I deserve it.” Just like you should not compare your own rate of weight loss to that of others post-op, it does no good to compare your metabolism to that of others. It’s an individual situation and journey!

Dr. Krainin, Thanks for this informative and helpful article on sleep disorders. This is a great description of what sleep apnea is and how obesity is related. I think it also underscores the importance of telling your surgeon everything about your health history. While I think most of us know that obesity can cause sleep apnea and weight loss surgery and weight loss can help it resolve, I had not realized that sleep apnea can lead to complications from weight loss surgery. It’s so critical to make sure your surgeon knows everything about your health conditions so you can have a healthy surgery! Looking forward to future articles in this series.

Thanks for the article and the good guidelines on how many reps to aim for depending on your experience and goals. Weight lifting can make such a difference as it boosts metabolism, improves blood sugar control, and makes you look and feel better all over. I also like that it gives me so many more options at the gym – rather than going for straight cardio every day, I can mix it up with strength training and even turn my weightlifting session into a heart-pounding workout if I set it up right. I think it’s also good to remind beginners that everyone was a beginner at some point, and it’s not something to be embarrassed about. If you belong to a gym, at the very least ask the staff there to show you how to use the weight machines or do certain exercises with cables, dumbbells, or other equipment. That’s what they’re there for, and proper form is very important to avoid injury. If possible, you can even get a session or two with a personal trainer. If you’re working out at home, online videos and good exercise DVDs can show you proper form. Make sure you pay attention! Thanks again for the great information.

Fat shaming adds insult to injury when you are obese or you have had weight loss surgery. Life is already difficult enough without the extra challenges of fat shaming. You may have health conditions, trouble moving and low energy levels if you are overweight. After weight loss surgery, you need to watch every aspect of your diet and lifestyle. Anyone who has struggled with weight can have low self-esteem and feel insecure at times. So why must you face “fat shaming,” too? Nobody should be forced to experience fat shaming, but unfortunately, it is a reality. It is a way of making people feel bad about their weight, often through subtle or less subtle passively aggressive words or actions. Here is some information about what it is and how you can fight it Why It Hurts Fat shaming hurts emotionally. It involved people judging you negatively for your appearance. Worse, they feel that you have no right to be at peace with who you are. Having others let you know day after day that you should feel inferior can drag you down, and that’s unfair. Think about an experience so many of us have had, and often on a weekly or even daily basis. When you order in a restaurant or check out at the grocery store, have you ever suspected that the server is thinking, “Why is this lady ordering a salad? She clearly eats way more than that at home.” Or do you see the skinny person in line behind you at the supermarket look at your cart and think, “She’d be better off skipping the Froot Loops and sticking to lettuce” (never mind that the cereal is for your kids). The fat shaming may be less subtle. “Excuse me, ma’am, but are you sure you should be buying that pasta? Should you stock up on celery sticks instead?” What nerve! Fat shaming can even hurt in practical ways. Take jobs, for example. Have you ever walked into a job interview only to see the interviewer look at you with disdain, so you know you’re not going to get the job because of your weight? How Bad It’s Gotten (Hint: There’s an App for That) Fat shaming is pervasive in our society. People don’t even realize it’s there. It’s just accepted that fat people are somewhat subhuman. Even doctors often assume that your obesity is your fault. “Just stop eating,” people say. No matter what they see you do in public – order broiled fish and broccoli at lunch, hit the gym every day, and faithfully chug your 8 glasses of water – they assume you’re ordering a couple of value meals at the drive-through on the way home, and curling up with a box of doughnuts every night. Fat shaming is so accepted in our society that there are even apps to promote it. They may show you what someone looks like when they’re a few pounds heavier (oh, the horror!), just to scare you away. The thing is, these shame campaigns don’t work. In fact, they even lead people to eat more because they feel inadequate. People who experience fat shaming are more likely to gain weight. And, if their doctors are doing it – which happens with shocking frequency – they may not seek or receive the medical care they deserve and need. The Obesity Action Coalition (OAC) is calling for tech giants to remove these apps from the market. What Leads to Fat Shaming? Fat shaming comes from the assumption that overweight people are not people. Fat shamers believe overweight people do not deserve respect. They just eat too much because they’re too lazy to eat right and exercise. Fat shaming can also come up out of a sense of insecurity on the part of the fat shamer. It’s a lot easier to point out the flaws of someone who’s overweight than to acknowledge one’s own shortcomings. Fat shaming is hurtful, and it needs to stop now! Pledge to Join the Fight You can sign up to join the growing movement against fat shaming. The Weight Loss Surgery Foundation of America (WLSFA) is sponsoring a challenge to fight fat shaming. You can sign up to post videos, pledge to stand up against fat shaming, and join the growing movement. You can get more information and resources from WLSFA Be the Change You can also work every day on your own to fight fat shaming. The WLSFA suggests vowing to fight ignorance with education and speaking up for others who are facing fat shaming. You can also vow to treat all people with respect because you know what it is to be treated disrespectfully for no reason. Fat shaming is deeply rooted in our society, and it hurts. You can fight this unfair practice by pledging with the WLSFA or taking your own steps to embrace your body, stand up for anyone who needs it, and love others, no matter who they are or what they look like.

@Louisa Latela, So true! Thanks for this! It is so important to remember that we are here, now, in this moment, and all we can and should do is know we’re doing the right thing for right now. Thanks!

Weight loss surgery is hard work, and being in a time crunch can be another challenge. After weight loss surgery, you may need to spend extra time planning meals, preparing your food, and working out. That time can become a barrier to success So how can you fit weight loss into your already-packed life? We have a few tips that can help you save precious minutes here and there. Serve one meal per family. Do you regularly make your family one meal and make yourself another? You’re doubling the time you spend cooking. You’re also showing your family that healthy eating is something that only YOU do, not something “normal.” Save time and make the healthy eating bandwagon more welcoming by planning to serve one basic meal at each family dinner. You can always alter it to make it a little lower calorie for yourself, or to add some of the treats that your family loves but that are off-limits for you. Take a spaghetti dinner, for example. You can skip the pasta but serve it to everyone else, while making lean ground turkey meatballs in tomato sauce with a side of veggies that you and everyone can enjoy. If you’re craving noodles, use some low-carb ones or make zucchini noodles. Then, if your family wants, offer extras such as parmesan cheese and garlic bread. It’s no extra work for you, and everyone gets what they want…while they get some good nutrients in them, too. Use meal helpers – the healthy ones. We’re not talking about boxes of rice or pasta helpers or family-sized frozen mac and cheese or pizza. We’re talking about healthy meal helpers, such as already-marinated chicken breast, pre-cut salad and veggies, and rotisserie chicken. They’re nutritious, and they save time. You can also stockpile instant high-protein meals for anytime. BariatricPal has tons of hot and cold breakfasts and lunch and dinner choices that are ready in minutes and designed for weight loss surgery patients. Choose them for breakfast or lunch at work, for a quick dinner, or when you just feel like a great-tasting entrée without needing to cook. Multi-task when appropriate. We’re not fans of multi-tasking when it comes to focusing. In fact, multi-tasking can actually be one of the biggest time-wasters of your day since it takes so much time to switch your attention from one task to another. But in its place, multi-tasking can be a brilliant time-saving move. Doubling up on family time and chores is one of the most sensible ways to multi-task. You’ll get to spend more time with your family, while making chores more pleasant and saving time. Take your children with you to the supermarket (bonus: they can learn to read food labels!), and work on household chores together. Cleaning the house is a lot more fun when it’s a family activity, and it’ll teach good habits and responsibility. Multi-tasking can also be a great way to fit more exercise into your life, since one of the biggest excuses for not getting active is lack of time. Walk them to and from school while you chat about their days. Walk laps, doing jumping jacks and squats, or even help out the coach and run drills with the kids if you’re watching your children’s sports practice. Encourage your children to play outside, and make it fun for them by being right there with them. Walk on a treadmill, use an exercise bike, or march in place while watching TV or during commercial breaks. Make movement part of life. Did you know moving for even a minute at a time can give you tons of benefits? There are plenty of ways to add in activity without taking an extra second of your time. You can try different games with yourself to see which works for you. You might decide to stand up every time you send a text message or check your phone, or remind yourself to walk around your office whenever you’re on the phone. Now, we’re not saying to quit your gym membership or give up on your regular workouts. Just know that every little bit counts, and getting in a few minutes here and there can keep your metabolism going and help you think more clearly…so you can make better food choices. Plan ahead to save time. Sometimes it’s hard to set aside a few minutes to plan the week’s meals, recipes, and grocery shopping, but it saves time overall. You’ll be able to zip through the grocery store and get meals on the table faster when you already know exactly what you’re making. Planning ahead can even let you plan for leftovers, so you don’t have to cook another meal just yet. You already know that sustainability is the key to long-term weight loss surgery success. The more you can fit your healthy weight loss surgery habits into your regular life, the easier it’ll be to keep up those good habits. They don’t need to take up much time as long as you plan them carefully.

Melissa, Thanks for these helpful tips! You have some great practical advice regarding having a Plan B and also to depend on yourself – not your friends and family – for your workout. In a lot of ways, sticking to your exercise plan is just like sticking to your eating plan after WLS. I would also add to #7 (Eat Around Your Workouts) to be sure to drink around them, too. So many WLS patients do not get enough Water as it is, and exercise increases your Fluid needs. On top of the 64 (or more) ounces you should be getting each day, you need more with exercise. Depending on how long you work out and how much you tend to sweat, you may need a few extra cups. It’s good to stay hydrated throughout the day, drink a cup or two about an hour before working out, have a few ounces every 15-30 minutes through the workout, and then down another cup or two after you’re done. Also I would suggest finding something, or preferably some things to do that you love. That makes it easier to be consistent. Having a bunch of options also makes it easier to stay motivated. Thanks for these super helpful tips!

There is one effect of obesity that does not get the attention it deserves. People don’t always mention it as a motivation for getting weight loss surgery the way they may list reasons such as improving their health, having more energy, and looking better. This very painful effect may not get the spotlight because it is such a personal matter, but it is something many overweight people struggle with. It is the ability to start a family. Healthy weight loss after WLS can help men and women overcome infertility and see their dreams of having a healthy baby come true. Obesity: Major Factor in Infertility About 1 in 8 couples has trouble conceiving and carrying the fetus to term. The rate is far higher among overweight men and women. Obesity causes hormonal changes in both men and women. In men, obesity can lower testosterone levels and make sperm less healthy. The result can be trouble fertilizing the woman’s egg. In women, obesity can lead to a disturbed menstrual cycle. Even when obese women have regular ovulation, they have a lower chance of establishing a pregnancy. If they do, they may have insulin resistance that can cause miscarriage or other harmful outcomes. If you are overweight, you may have tried to become pregnant for years without success, or without being able to carry a healthy baby to term. Fertility treatments such as IVF can help, but your chances of success are lower when you are obese. Obesity and Pregnancy: A Dangerous Mixture Obesity can also make pregnancy more dangerous. The mother is more likely to have gestational diabetes and preeclampsia, or high blood pressure and damage to the kidneys. There is a higher risk of C-section delivery, overdue delivery, and infections. Your child may be at higher risk for birth defects, obesity, and diabetes later in life. Weight Loss Surgery to Achieve Your Dreams of a Healthy Family If you are dreaming of starting a family or adding to yours but you have been unable to, obesity may be getting in your way. If you have tried other weight loss methods and none have worked for you, WLS may be the answer. As long as you follow the necessary diet, WLS can help you get your weight down to a level that can support a healthier pregnancy. Weighing the WLS Decision Should you get WLS to improve your chances of being able to have a baby? It might be a good option for you if you meet the criteria: for example, if you have not been able to lose weight and keep it off with diet and exercise alone, if you meet the BMI requirements for WLS, and if you feel ready to commit to the required diet – for life. The next question is the same one faced by all WLS patients: which type of surgery should you get? Just like any other WLS patient, you have to make the decision that is best for you. The lap-band has the advantage of being completely adjustable, so you can get it loosened while pregnant in order to get more nutrients. However, many gastric sleeve and gastric bypass patients have healthy pregnancies, too. Finally, consider the time-frame. You should wait at least 12 to 18 months after surgery before planning to get pregnant. That’s because you are better off getting pregnant after you hit goal weight. As soon as you get pregnant, you will need to stop losing weight if you want to support the baby’s proper growth and development. Supporting a Healthy Pregnancy: Don’t Let down Your Guard After weight loss surgery, it is harder to get in all of your nutrients. Plus, surgeries like the gastric bypass can reduce nutrient absorption. To make sure you are staying nourished and providing the fetus the nutrients it needs for development, you may need a prenatal multivitamin and mineral supplement, plus additional vitamin D, vitamin B12, iron, folic acid, and calcium supplements. The amount of weight you gain is critical, but it may take some mental preparation to allow yourself to gain weight after the 12 to 18 months you just spent working to lose weight. Also, be aware that you may still have a higher risk for complications if you are starting your pregnancy at an overweight BMI. Your ob-gyn should monitor you carefully. You may need to educate your ob-gyn if he or she is not used to caring for WLS patients! A Healthy Foundation for Years to Come Of course, a healthy family isn’t just about the newborn. With WLS, you may develop long-term healthy habits that your children will pick up on as they grow up. You can teach them to love healthy foods and to beg to play outdoors – with their active parents! Some WLS patients get off track after hitting goal weight because there is less motivation and excitement during the maintenance phase. You have the advantage of having plenty of motivation. How much more motivation do you need than having many more healthy years left to enjoy your family and watch them as they fit the healthy habits you modeled for them into their own lifestyles? There are almost unlimited reasons to get WLS, and one of them is starting a family. If that’s one of your goals, talk to your doctor and surgeon about it. You may be able to achieve this dream more easily than you had dared hope.

@My Bariatric Life, As always, great article! You have so many insights here about getting ready for a successful WLS journey. It is so tempting and common to postpone “the conversation” about what will happen after WLS. It is so easy to just hope things will fall into place; that either your weight loss surgery or new lifestyle will not change your relationship, or that your relationship will change to accommodate your new lifestyle. It is necessary to face the possible changes head-on and in advance, as you say. I would also add one more thing, which is the possibility of looking at this in a positive light. You and your partner can look at what the relationship can gain from your weight loss surgery, and emphasize the positives rather than what you may lose. For some things, there’s no need to wait until WLS to start. For example, the couple can start to cook together, or take walks together, before you get WLS. Thanks for the good article!

Thanks so much for this great article! What a way to honor these women on Mother’s Day. I love the way you gave us beautiful examples of women at different places in their lives and who had different choices of weight loss surgery type and also an example of plastic surgery. Jassira’s story in particular shows what women can go through in order to become mothers. I don’t think that motherhood is always appreciated as much as it deserves. Congratulations to each of these strong women and the many others like them. This is a great way to Celebrate these and other women who have worked so hard and shown so much dedication not only to themselves and their health, but also to their families.

Imagine this. You and your doctor agree that you need to lose weight. You tell your doctor you’ve been thinking about weight loss surgery. Your doctor lets you know his or her thoughts about WLS, and they’re very negative. You may not need to imagine it because it may have happened – or be happening – to you. What should your next step be when your own doctor is not supportive of WLS? Doctor’s Orders: Lose the Weight Almost all Weight Loss Surgery patients and nearly everyone who’s considering getting WLS had a similar experience to the following. You go for a routine visit to your primary care physician, endocrinologist, or regular doctor, and you get the news you’ve come to expect: you’ve gained a little weight since the last appointment and you’re developing obesity-related problems. Bottom line, your doctor says, is that you need to lose weight. It’s no secret that you need to lose weight. You’ve probably tried a thousand different diets. They may have worked, but only for a time. Then any weight that left came right back, with a few extra pounds. You recently started thinking about weight loss surgery, and you bring up that idea to your doctor. “Weight Loss Surgery Is the Wrong Choice” Some doctors are against weight loss surgery. They have the same reasons as anyone else who may be against weight loss surgery. They say it’s the easy way out, or you can lose weight on your own, or you might have complications. It’s great for them to express their concerns to you since that’s their job. But it’s not okay to deny you the opportunity to lose weight just because they don’t like the idea of WLS and may not have ever done any research into it. The Ideal Doctors are supposed to be compassionate, understanding, and competent. If that sounds like a tall order, it is. But it’s not unrealistic. You need to feel comfortable discussing your health and health decisions with your doctor without your doctor making you feel like a failure for not losing weight already and for considering Weight Loss Surgery. You Come First Your doctor should put you first. Putting you first means taking into consideration your future health, your dieting and weight history, and your own beliefs about whether weight loss surgery is right for you. Your doctor should put you ahead of any personal beliefs or biases about weight loss surgery, or lack of knowledge about it. Seeking a “Second Opinion” You’re always entitled to a second opinion when it comes to your health and healthcare decisions. You may not need an official “second opinion” on whether you should get WLS if you’ve already decided you’re going for it. What you do need is an opinion from a doctor who will support you. You can consider switching your primary care doctor if it’s important to you that your PCP be supportive of your WLS journey and during it. You may even want to find a doctor with some understanding of WLS and how to help you prepare for and recover from it. That’s not always possible, for insurance and logistical reasons. It may not be desirable if you like your PCP otherwise and don’t want to jump ship. A Supportive Bariatric Surgeon Whether or not your family doctor approves of Weight Loss Surgery, your surgeon absolutely needs to be on your side. While you can expect bariatric surgeons to be supportive of you getting WLS, that’s not the only thing to consider. Consider whether the surgeon makes you feel confident you’ll get the support you need and that you will succeed. Whether because of their poor bedside manners or lack of attention to detail, some surgeons will keep you in doubt about your decision. Those are not the right surgeons for you! You may need to have initial consults with one, two, three, or even more surgeons before settling on the one that’s going to boost you up. A Personal Decision Ultimately, weight loss surgery is your decision. You can decide to get it, or not to get it. It should be a decision based on what you think will help you lose weight, how much risk you’re willing to take by going “under the knife” (although it’s laparoscopic these days!), and how you think it stacks up against your other options. It should NOT be a decision based on what your doctor thinks or how uncomfortable you feel talking to your doctor or surgeon about it. It’s up to you.

@Dr. Fielding, Thanks for this informative article and for sharing your insights about the lap-band. You have so many great points here about the role of the lap-band, the role of the patient, and the role of the surgeon. I am very impressed that you encourage your patients to come back monthly for 18 months – that’s more than many surgeons ask for, and that may be why your patients are so successful. I like the way you emphasize that the lap-band needs to be properly adjusted and placed for it to work, and the patient needs to follow the rules. I also love that you recognize real life: the patient can and should eat out and enjoy life and eating, and it’s possible to do that while sticking to the lap-band diet. Thanks also for the reminder that it’s okay to go back to the surgeon for an adjustment even if it’s been a little too long since the last one.