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The Doc: Post-ops – this one’s for you! (However, if you're a pre-op, you'll benefit a bunch by reading this before your procedure!) A friendly warning for everyone reading this article – pre- or post-op – these words are not for the faint of heart! You're going to be asked some questions and also asked to be 100% completely honest with yourself as you answer the questions! Don’t worry too much. The questions are few in number. You don’t even have to tell anybody else your answers, but if you tell yourself even a “little white lie” you’ll be doing yourself a great disservice. The reason? Recovery from obesity requires being completely honest with yourself about what you are doing and what you’re not doing to manage a healthy weight. Then you have to honestly decide what you are willing to do if you want what you told your weight loss surgery medical team you wanted: your health back and to be able to do things you couldn't when carrying an extra 100 + pounds.


The Post Op: Sounds ominous, doesn’t it? Just what are these questions? Can you flunk the test? The good news is, this isn’t a test, but the questions can test your patience a bit, and might be challenging to answer. The goal is honesty, so just do your best and don’t worry, we’ll go easy on you. It won’t take long to figure out that there are many more questions where these came from (and the answers will likely be the same!)
What the Nutritionist told you (and hopefully the psychologist, your PCP and the WLS surgeon, as well):
1. In some way, shape or form, during your pre-surgical preparation, the dietician told you that in order to keep your weight off over time, you are going to have to eat “healthy” portions of the right foods (and by “healthy” we do not mean “healthy” = huge; we mean “healthy” as in nutritionally healthy portions = measured/reasonable amounts of food).

Questions:
a. Did you get this message during your pre-surgical preparation for WLS?
b. Did you agree that you would, indeed eat “healthy” portions of food after the surgery (with an implied, forever more)?
c. Did you mean what you said when you agreed to maintaining “healthy” portions of the right foods after surgery? (I’m fairly certain you did mean it.)
d. ARE YOU DOING IT? Are you maintaining “healthy” portions of the right foods ever since you’ve had WLS?
a. If not, what’s up???
b. If not, what are you willing to do in order to get back on track with this? 2. In some way, shape or form, during your pre-surgical preparation, the dietician told you that in order to keep your weight off over time, you need to eliminate or reduce/minimize the simple carbs that you eat (meaning white rice, white potatoes, pasta, white bread, most “baked goods,” “junk food,” and sugary foods (most “baked goods,” candy, soda, sweet tea, cake, cookies, etc.).

Questions:

a. Did you get this message during your pre-surgical preparation for WLS?
b. Did you agree that you would, indeed eliminate or reduce/minimize the simple carbs that you eat (meaning white rice, white potatoes, pasta, white bread, most “baked goods,” “junk food,” and sugary foods (most “baked goods,” candy, soda, sweet tea, cake, cookies, etc.)?
c. Did you mean what you said when you agreed to eliminate or reduce/minimize the simple carbs that you eat (meaning white rice, white potatoes, pasta, white bread, most “baked goods,” “junk food,” and sugary foods (most “baked goods,” candy, soda, sweet tea, cake, cookies, etc.)? (I’m fairly certain you did mean it.)
d. ARE YOU DOING IT? Have you eliminated or reduced/minimized the simple carbs that you eat (meaning white rice, white potatoes, pasta, white bread, most “baked goods,” “junk food,” and sugary foods (most “baked goods,” candy, soda, sweet tea, cake, cookies, etc.)ever since you’ve had WLS?
a. If not, what’s up???
b. If not, what are you willing to do in order to get back on track with this? What the Physician told you (bariatric surgeon and/or primary care physician):
3. It is important that you utilize the first 12 – 18 months (the “honeymoon period”) to establish healthy lifestyle habits regarding food and exercise.

a. Did you get this message during your pre-surgical preparation for WLS?
b. Did you agree that you would, indeed utilize the first 12 – 18 months (the “honeymoon period”) to establish healthy lifestyle habits regarding food and exercise?
c. Did you mean what you said when you agreed to utilize the first 12 – 18 months (the “honeymoon period”) to establish healthy lifestyle habits regarding food and exercise? (I’m fairly certain you did mean it.)
d. ARE YOU DOING IT? DID YOU DO IT? Are you/Did you utilize the first 12 – 18 months (the “honeymoon period”) to establish healthy lifestyle habits regarding food and exercise?
a. If not, what’s up???
b. If not, what are you willing to do in order to get back on track with this? 4. It is important that you engage in and maintain some form of physical exercise (keeping in mind your physical conditions) more days of the week than not, in order to maintain your weight loss.

e. Did you get this message during your pre-surgical preparation for WLS?
f. Did you agree that you would, indeed engage in and maintain some form of physical exercise (keeping in mind your physical conditions) more days of the week than not, in order to maintain your weight loss?
g. Did you mean what you said when you agreed to engage in and maintain some form of physical exercise (keeping in mind your physical conditions) more days of the week than not, in order to maintain your weight loss? (I’m fairly certain you did mean it.)
h. ARE YOU DOING IT? Are you engaging in and maintaining some form of physical exercise (keeping in mind your physical conditions) more days of the week than not, in order to maintain your weight loss ever since you’ve had WLS?
a. If not, what’s up???
b. If not, what are you willing to do in order to get back on track with this? What the Psychologist/Mental Health Provider told you:
5. It is important that you fully understand that unless you do what the doctor and nutritionist tell you to do for the rest of your life, you can (and most likely will) regain your weight. Are you willing to follow through with the nutrition and exercise guidelines after surgery in order to keep the weight off? (And if you’re lucky, they encouraged you to seek therapy if you struggle).

a. Did you get this message during your pre-surgical preparation for WLS?
b. Did you agree that you would, indeed, do what the doctor and nutritionist told you to do for the rest of your life, or you could (and most likely would) regain your weight?
c. Did you mean what you said when you agreed to do what the doctor and nutritionist told you to do for the rest of your life, or you could (and most likely would) regain your weight? (I’m fairly certain you did mean it.)
d. ARE YOU DOING IT? DID YOU DO IT? Are you doing what the doctor and nutritionist told you to do in order to prevent regaining your weight?
a. If not, what’s up???
b. If not, what are you willing to do in order to get back on track with this? ARE YOU WILLING TO GO TO THERAPY? The Post Op & The Doc:
Above we have noted five topics basic to nearly every surgical weight loss program in this country:

1) the need to eat healthy portions of healthy foods,
2) the need to minimize simple carbohydrates,
3) using the first year to learn and implement healthy habits,
4) engaging in, and maintaining healthy support, and
5) it is possible to regain weight after WLS if you don’t follow what you were advised to do. The Post Op & The Doc have seventeen years collectively working in this field. We have seen and talked with thousands of patients who have shared with us that they did hear this information before surgery, they agreed to do what they learned, and they meant it. Yet many have been unable to follow through. That’s normal. It’s difficult to make the behavioral changes needed to keep weight off. If you start to regain, you can catch yourself and get headed in a healthy direction.

Many people are doing what it takes to get back on track so that they can get and keep their excess weight off. They do what they set out to do when they decided to have weight loss surgery: Improve their health and have the ability to do more of the things they want to do.

The best way to get into the habits needed to maintain a healthy weight or to get back on track is to use the Gotta Do Em's. The Gotta Do Em's are what it takes to get and keep weight off:

1. Make Healthy Food Choices
2. Maintain Portion Control
3. Exercise Regularly
4. Drink Water
5. Eat Breakfast
6. Plan Your Meals and Follow Your Plan
7. Keep a Food Diary
8. Keep an Exercise Diary
9. Use a Healthy Support System
10. Get Individual and/or Group Therapy There are lots of excuses for not following the Gotta Do Em's. It would be easy to say that you were overwhelmed with all of the information you were given pre-surgery and couldn’t possibly understand everything you agreed to. It would easy to say that you were just trying to get your forms completed so you could qualify for surgery and you therefore agreed to whatever you needed to. It would be easy to say you didn’t know then what you know now, so you were committing to things you weren’t prepared to honor.

Well, none of that matters because, the truth is, you can do what you said you would do and, if you really want what you say you want (improved health and a better quality of life), you must do those things you said you would.

The good news? You don’t need to do them alone. In fact, as A Post Op & A Doc always say, “No one can do this for you, but you can’t do it alone.” We all need support to sustain the Gotta Do ‘Em's. So utilize the support offered by your medical team, your program’s support group, and the people who love you and do the things you said you’d do! You’ll feel great about yourself and will get the results you were looking for as you headed into weight loss surgery.
A Post Op & A Doc have a copy of the Gotta Do ‘Em’s (and a lot more free handouts for you) at www.conniestapletonphd.com/apod and on our Facebook page at http://www.facebook.com/apostopandadoc .

Cari DeLaCruz (The Post Op)
cari@apostopandadoc.com
www.conniestapleton.com/apod

Connie Stapleton, Ph.D. (The Doc)
connie@apostopandadoc.com
www.conniestapleton.com/apod

After weight loss surgery, you need to plan your meals ahead of time. You always want a high-protein, low-calorie option to be available at meal time. You might find yourself carrying your own prepared food with you to be sure that you have the food you need. Sandwiches are good “go-to” option, but not just any old sandwich will do! This article can help you build sandwiches that are good fits for your meal plan.


What is Wrong with the Sandwiches You Used to Eat?
A typical workday might have started off with a trip through the drive-through for a breakfast burrito or sandwich, or a bagel and cream cheese sandwich at work. Lunch could have been a brown bag peanut butter and jelly sandwich or a trip to a nearby restaurant for a sandwich, burrito, or burger. Where might these options leave you?
Sausage, egg, and cheese croissant or biscuit from a drive-through (600 calories with 42 grams of fat)
Bagel with cream cheese (500 calories with 70 grams of carbohydrates)
Peanut butter and jelly sandwich (600 calories and 40 grams of sugar)
Club sandwich (1,000 calories and 2,500 milligrams of sodium)
Chicken patty sandwich (60 grams of carbohydrates and 1,100 milligrams of sodium)
Beef, bean, and cheese burrito (900 calories and 40 grams of fat)

Your breakfast and lunch sandwiches could have added up to over 1,500 calories. Add in beverages, sides (hash browns, fries or chips, anyone?), and snacks, and you could have been at 3,000 calories by lunchtime!
These Choices Don’t Work After Weight Loss Surgery!
Needless to say, these options do not fit into your weight loss surgery diet.

First, some of those sandwiches have more calories than you are supposed to be eating in a day, not to mention that some also contain more saturated fat, sodium, and sugar than you should have in a day.
Second, those sandwiches emphasize starchy breads and fatty condiments, not the lean proteins and nutritious vegetables you need to stay full and nourished after weight loss surgery.
Third, they can cause complications. Doughy bagels and fried chicken, for example, can cause obstructions in lap-band patients; fatty sausage and sugary jelly can cause dumping syndrome in gastric bypass patients; and these low-nutrient foods can fill you up and cause malnutrition.

Luckily, this does not mean that you need to give up the convenience of sandwiches and the pleasure you get from biting into one. There are plenty of ways to make sandwiches that are weight loss surgery-friendly: low-calorie, high-protein, convenient, and delicious!
Protein Fillings for WLS Sandwiches
Start by choosing a lean source of protein, just like you do when you plan all of your meals. These are some healthier options compared to what you might have chosen before weight loss surgery. Don’t forget to measure your portions if you are making your own sandwich, or eyeball your portions if you are ordering in a restaurant.
2 scrambled egg whites (30 calories)
2 ounces of canned light tuna (60 calories)
2 ounces of chicken breast, lean ham, turkey breast (80 calories)
2 ounces of fat-free cheese (90 calories)
½ cup cooked beans or 1 vegetarian burger (120 calories)
2 ounces of turkey or vegetarian bacon or breakfast sausage (130 calories)

Load up on Vegetables and Fruit
Vegetables and fruit are the next food groups to add to your meals. Vegetables especially are low-calorie, so add more if you want a bigger sandwich. Try classic combinations, or get creative. You can also experiment with herbs such as fresh cilantro, basil, and dill. These are some ideas.
Lettuce and tomatoes with meat and cheese
Grilled eggplant, zucchini, and/or bell peppers with beans
Cucumbers and sprouts with fat-free feta cheese
Diced celery, carrots, onions, and water chestnuts with tuna
Spinach and mushrooms with egg whites
Pear or apple with fat-free cheddar cheese
Cantaloupe with ham and/or fat-free cheese
Blueberries with egg whites

Breads and Alternatives
Most bread is high in carbohydrates and low in protein – clearly not what you need for your nutritious weight loss surgery diet. Besides adding calories and carbs, bread can cause obstructions in lap-band patients and make gastric bypass patients sick or overly full. When possible, skip the regular bread.
Bagels
Tortillas
Subs
Croissants
Biscuits
Regular sliced bread

Instead, choose whole-grain, high-fiber, low-calorie breads, and consider open-faced sandwiches, with the filling on 1 slice of bread, instead of regular 2-slice sandwiches. These are some good options.
Reduced-calorie bread (45 or fewer calories per slice)
Light English muffin (50 calories per half)
Mini whole grain bagel (60 calories per half)
Low-carb tortilla (50 calories per small tortilla)
High-fiber, light wrap (90 calories per wrap)
Also, look for creative, non-bread alternatives.
Lettuce leaves to make lettuce wraps or cups
Egg roll or wonton wrappers
Sheets of dried seaweed
Grilled eggplant
Your fork (skip the bread and just eat the filling)

Keeping Condiments Under Control
The condiments that you add can make or break your sandwich, both in terms of nutrition and taste. Skip the full-fat mayonnaise, dressings, dips, sour cream, and butter, and be wary of high-sugar jam, barbecue sauce, and honey mustard. Instead, consider the following condiments.
Salsa
Fat-free mayo, dressing, dip, or sour cream
Regular mustard
Plain, non-fat Greek yogurt
Hot sauce
Shredded fat-free parmesan cheese
Reduced-calorie, trans fat-free margarine

Some Breakfast Sandwich Ideas to Start Your Day Off Right
Egg whites scrambled with spinach, mushrooms, and fat-free feta cheese on ½ English muffin
Cottage cheese and strawberries wrapped in lettuce leaves
Shredded fat-free cheese and lean ham toasted on a slice of reduced-calorie, whole-wheat bread and topped with salsa and tomatoes
Egg whites cooked with turkey bacon and broccoli in a small, high-fiber wrap
½ whole-grain mini bagel spread with fat-free cream cheese and topped with canned salmon with diced celery and water chestnuts

Lunch Sandwiches
Lettuce wrap filled with diced chicken breast, bean sprouts, mushrooms, and bell peppers, and soy sauce or light Asian dressing
Dried seaweed sheet rolled around tuna salad made with fat-free mayo, chives, and celery
Pinwheels made by layering slices of turkey breast, lean ham, and fat-free cheese slices, spreading them with mustard, and rolling them
Bean burrito with black beans, fat-free cheddar cheese, salsa, and fat-free sour cream on a small, high-fiber tortilla
Chicken breast with sliced apple and light vinaigrette between slices of grilled eggplant
Tomato sauce, fat-free mozzarella cheese, and mushrooms on a light English muffin
Toasted Rueben sandwich with low-fat Swiss cheese, shredded cabbage or sauerkraut, lean corned beef, and fat-free Thousand Island dressing on a light English muffin

Are You Ready for Some Sandwiches?
You can eat these sandwiches at home, or make them ahead of time and carry them with you in a reusable container. As a weight loss surgery patient, you should own plenty of reusable containers with tight-fitting lids. If you do not already have some, they are worth the investment so that you can carry healthy foods with you wherever you go.
We hope that you enjoy these sandwich ideas and that you are inspired to make some of your own healthy, high-protein sandwiches!

Are you struggling to get your fruits and veggies down? Here are some strategies to help you enjoy the good produce that yields good health.


Believe it or not, I actually love the fruits and veggies my doctor tells me will keep me healthy. When I was growing up, no one had to tell me that, like Popeye, I needed to eat my spinach. I’d rather not eat greens out of a can, but decades later, they appear on our dinner table often.
At home here in rural Tennessee, we enjoy many months of harvest from our big garden and small orchard. We are truly blessed in the produce department. The problem is that the harvest is too big for a big man and a small woman to eat. We give a lot to friends, coworkers, and the local food pantry, but my husband continues to overestimate how much I can eat nowadays, and I continue to work on strategies to make produce easier for my altered upper GI tract to handle.
During my pre- and post-op nutrition classes, my dietitian warned us that fruits and vegetables are a challenge for most gastric band patients to eat, and repeated the “take tiny bites and chew each bite 100 times” mantra many, many times. It took several months and band fills for me to truly understand why Susan had repeated her warning so often, and what was true for me as a bandster is still true for me as a sleevester. If you’re in the same situation, I offer you a delicious mixed salad of produce prep ideas.
But first, let me address the juicing of fruits and vegetables. It's true that juice is easy to get down. It’s true that you can get vitamins, minerals, and flavor from juiced fresh vegetables and fruits. It’s true that you can add protein powder to juice to amp up its nutritional benefits. But even the freshest juice won't give you the fiber and satiety of the solid versions. One of the things I like best about raw produce is its CRUNCH. Just the act of crunching a carrot makes eating it so satisfying to me. And no one can convince me that juicing is convenient. I used the fancy juicer my helpful husband gave me at the time of my surgery exactly twice. I love to cook and love kitchen toys, but assembling, cleaning, and reassembling a juicer takes far more time than I’m willing to give a glass of juice that takes me all of a minute to drink. I stuck to my pre- and post-op liquid diets like a good girl, but if I’d believed I could lose my excess weight and maintain a healthy weight by consuming liquids for the rest of my life, I wouldn’t have had bariatric surgery in the first place!
Here are some suggestions that might make it easier to eat your fruits and veggies, both raw and cooked.
Peel and seed everything within reason, except perhaps grapes (unless you can find yourself a cute slave boy to peel your grapes for you - and if you find one, ask him if he has a brother or sister who would like to move to Tennessee - MUST LOVE DOGS). It's easy enough to peel fruits like tomatoes, peaches and plums by dunking them in a boiling water bath for a minute. The skins of bell peppers can be a problem for me, but if you grill or broil the peppers until they're charred, the skins slip right off (you'll have to rinse off the stubborn bits) and the roasted flavor is wonderful.
If eating fruits or vegetables "out of hand" (such as two of my favorites - carrot sticks dipped in hummus and apple slices smeared with with peanut butter) is a problem for you, cut them into small pieces and eat them with a fork. When I eat with utensils instead of my fingers, I automatically eat more slowly and carefully.

Try shredding the food in a food processor. At times I haven't been able to eat broccoli, Brussels sprouts, cabbage, carrots, apples, spinach, kale and other things whole or even chopped, but they worked if I shredded them before I cooked or ate them.

Try alternating bites of a challenging fruit or vegetable with a less challenging food. For example, instead of just eating a banana, cut it up and mix it with other cut fruits and berries in a salad. Then (slowly) eat a bite of banana, a bite of melon, a raspberry, and so on. Or eat a bite of strawberry, then a bite of cottage cheese. “Lubricate” fresh blueberries by mixing them into thick, yummy, protein-rich Greek yogurt (a sprinkle of chopped nuts in that makes it even better).

Although I prefer fruits and most veggies raw, sometimes I have to do what my grandmother called "blanching". Bring a pot of water to boil. While it's heating, cut up the fruits or veggies into small pieces. When the water is boiling, throw the produce in, turn off the heat, and let it sit for one or two minutes. Then drain it and run cold water over it (or put it in an ice bath) to stop the cooking. The produce should still have its bright color and it hasn't lost a lot of nutrients, crunch, or flavor this way, but the parboiling takes some of the meanness out of the fibers.
Just before serving, mix the raw or cooked produce with a sauce, yogurt, light sour cream, hummus, dip or low-fat dressing. Sometimes all any food (including meat) needs is a lubricant to help it go down. Just don't overdo the sauce so that it covers up the flavor of the food and sends a flood of saturated fat into your circulatory system.
Corn kernels can be a challenge for us to eat (cooked or popped) because of the fibrous hulls. That doesn’t mean you can never eat corn again. It just means: eat it carefully, and in moderation. It’s mighty hard to eat corn-on-the-cob carefully, so I slice the kernels off the cob (which also reduces the annoyance of corn stuck in the teeth. I’ve also had good luck with fresh corn if I cut the kernels off the cob before cooking the kernels. Hold the corn cob so it stands with its stem end on a plate or bowl. Run a sharp knife from the tip of the ear straight down to the stem end, leaving 1/8 to ¼” of pulp behind on the cob. Then cook the cut corn with a little bit of water or broth, or proceed with your recipe. Use caution when eating generic brands of frozen and canned corn, which in my experience contain more tricky and/or indigestible stuff (like bits of cob) than the more expensive name brands.
If you love fresh fruits and veggies too, y’all are welcome to pick all you can eat from our garden and orchard this year. To find us, get yourself to Memphis and drive north until you hear barking. I must warn you, though, that our dogs love produce too, so you may have to negotiate your share of the apple harvest with them. But they also love company, so come on down!

Those who have had weight loss surgery often ask how much they should be eating. Whilst is seems a simple question, there is no simple answer.


Those who have had weight loss surgery often ask how much they should be eating. Whilst is seems a simple question, there is no simple answer.
How much you should be eating is a hot topic on many online forums or support pages. If you have read the discussions it becomes clear that weight loss surgery clinics and support teams widely differ in how much they are recommending their patients eat. This is also clear when I chat with other health professionals at our obesity surgery conferences. If the professionals working in the area can’t get their story straight, how are people to know what to do?
Some surgeons recommend you limit meals to half a cup, some may say one cup, and others will say a bread and butter plate of food. Interestingly, one cup of food nicely fits on a bread and butter plate and this is the guide we use in our clinic.
Accredited Practising Dietitians (in Australia, Registered Dietitians in the USA) are university‐qualified experts on food and nutrition. Whilst even their recommendations on what you should eat following surgery will vary, what they will generally agree on is that it is difficult to meet your nutritional requirements eating half a cup of food, three times a day.
To date, there are no scientific studies on the exact amount of food people should include after gastric band and gastric bypass surgeries. Hopefully in time this will evolve. Research from Mercy Bariatrics in Perth, Western Australia, provides some excellent data to help guide serving sizes for those who have had a sleeve gastrectomy. Whilst initially very small amounts are tolerated, at six months after surgery most people will manage about half a cup of food at a time. By 12 to 18 months most people will manage about one cup of solid food. This is a guide only and will vary between people as there are different size sleeves.
A point relevant to all surgeries is that the people studied found they could indeed ‘fit’ more food in than what they felt satisfied with. After all forms of weight loss surgery, eating to the maximum amount you can tolerate is not recommended. I have a favourite quote from Dr. Teresa Girolamo, one of the GPs in our clinic: “It’s not a matter of seeing how much you can eat and get away with, but how little you can eat and be satisfied.” Testing the limits of how much you can eat increases your intake, particularly if it occurs repeatedly, and can compromise your results. Tune in to your feeling of satisfaction after eating and let that guide the amount of food you need to eat. Always stop eating before you feel any discomfort.
Create an environment that makes it easy for you to eat small portions. Ensure family and friends know you use a smaller plate/bowl/cutlery. Take these items with you if you travel. When eating out, order entrée size meals or if there are none available, separate your meal into an appropriate portion before you start eating. Tapas style menus, Asian or Indian eateries are often tailored to meals being shared, allowing you to dish up a small serve to suit your needs. It is fine to leave food on your plate when you have had enough, even if it is a smaller serve. Avoid the temptation to ‘clean the plate’. If ‘wasting’ food concerns you, carry a container with you when you eat out and take a serve home to have for another meal.
After gastric band surgery some people may find it takes some time before they feel satisfied on small amounts of food. Many people need their gastric band adjusted several times to help them feel satisfied on small serves. If small meals of solid food do not satisfy you, keep in regular contact with your support team until they do. Some people will find this will occur early in their journey, for others it may take longer. Be patient.
Whilst it is not necessary for you to measure or weigh everything you eat, it may be helpful to measure the amount you are usually serving. When you eat a meal, take note how much food it takes for you to feel satisfied and how much it takes to feel full. The aim is to feel satisfied after eating, so if you know roughly how much food this is you can avoid dishing up too much in future.
The recipes in my book and on my blog have been designed to provide approximately four, one cup serves. This does not mean a one cup serve is right for everyone, but does allows you to easily adapt the recipes to your requirements.