Connie Stapleton PhD

@@OKCPirate Thank you for the very kind message. Much appreciated.

@@SweetPeas Glad to hear that Mayo is giving a consistent message. And glad that it's not overbearing. My point is not about being absolute or overbearing... it's specifically related to the bariatric professionals who are the "leaders of the pack." My position is that this governing body needs to have a more definite RECOMMENDATION, based on the fact that alcohol is a toxin that can have deleterious effects on the absorption of essential nutrients, in addition to other possible negative effects. A recommendation is different than a "thou shalt not." Now that pizza... that's another issue all together! Take care and thank you.

@@CowgirlJane I'm with you on the cigarettes! We could certainly rant about that! Please remember that my comments are specifically related to the bariatric professionals who are the "leaders of the pack." My position is that this governing body needs to have a more definite RECOMMENDATION, based on the fact that alcohol is a toxin that can have deleterious effects on the absorption of essential nutrients, in addition to other possible negative effects. A recommendation is different than a "thou shalt not." Thanks.

@@Christinamo7 Given that alcohol is a toxin, then it's not a "wise" thing for anyone to do, really! But I'm not saying anything about no one, WLS patient or not, EVER having alcohol. Every person is individually responsible for whatever they put into their bodies. My message is not about judging those who drink or smoke or whatever... My message is about a governing body taking a more clear stance in their RECOMMENDATION. Please remember that my comments are specifically related to the bariatric professionals who are the "leaders of the pack." My position is that this governing body needs to have a more definite RECOMMENDATION, based on the fact that alcohol is a toxin that can have deleterious effects on the absorption of essential nutrients, in addition to other possible negative effects. A recommendation is different than a "thou shalt not." Thank you for sharing your thoughts.

@@OKCPirate I agree very much with the minister's quote: "very little good comes form the absolute shall." Please remember that my comments are specifically related to the bariatric professionals who are the "leaders of the pack." My position is that this governing body needs to have a more definite RECOMMENDATION, based on the fact that alcohol is a toxin that can have deleterious effects on the absorption of essential nutrients, in addition to other possible negative effects. A recommendation is different than a "thou shalt not." Thanks for the website referral. I'll definitely look at it! I definitely agree that people are different and also agree with Dee Hock. I am suggesting that there are simple, clear recommendations with the medical reasons as to why alcohol is contraindicated for WLS patients. I'm not saying to set rules. I'm so glad hearing that you and your kids have great communication. Very awesome. Thank you so much for sharing your thoughts!

@@CowgirlJane I love your comparison between alcohol and ice cream and how one calls your name and one doesn't. I also completely agree that WLS is not a "one size fits all" kind of thing. People definitely need to know the things that may need to be "off limits" for them and make healthy decisions accordingly. That will be different for every person. Please remember that I am only talking about RECOMMENDATIONS. And recommendations from those who are the governing body of WLS. It's not about saying ALL or NOTHING, nor does where I am coming from having anything to do with WLS patients being able to make good decisions - or not. What I am saying is that BECAUSE alcohol is a toxin and may interfere with absorption of essential nutrients, the governing body's RECOMMENDATION, not MANDATE, be that it is not a wise decision to consume alcohol after weight loss surgery. Thank you!

@@2goldengirl Please remember that I am only talking about RECOMMENDATIONS. And recommendations from those who are the governing body of WLS. It's not about saying ALL or NOTHING, nor does where I am coming from having anything to do with WLS patients being able to make good decisions - or not. What I am saying is that BECAUSE alcohol is a toxin and may interfere with absorption of essential nutrients, the governing body's RECOMMENDATION, not MANDATE, be that it is not a wise decision to consume alcohol after weight loss surgery. I totally agree that each and every person is responsible for their own health. Thank you!

@@Tssiemer1 You CAN drink wine... it's just not a very good idea!

@@SweetPeas So glad to hear that the medical professionals on your team said no alcohol! Where did you have your surgery? @@SweetPeas So glad to hear that the medical professionals on your team said no alcohol! Where did you have your surgery?

@@VSGAnn2014 Very nicely stated. Thank you for adding your experience! I agree with your psychologist on several points but not on others. I have also had certification as an alcohol and drug therapist for 25 years, so in addition to my 12 years specifically in the field of bariatrics, I have an extensive background in substance abuse. The data is limited about alcohol and WLS. I happen to think the problem is much more extensive than the literature suggests regarding transfer addiction. No matter what, alcohol is and always will be a drug, a toxin and has an effect on the absorption of nutrients. You, and all persons, are free to choose what to eat and drink! I'm very sad to hear about your husband. Please take care of yourself while you are caring for him. Thank you. Connie

@@OKCPirate Thank for the reading by John Grisham! Indeed, a very good narrative! As I have said, I don't have a problem with people drinking alcohol - if it's not contraindicated for them for whatever reason. I stand firm in my belief that for those who have WLS, alcohol has no place in their "diet." Very much enjoyed the video! Connie

@@Inner Surfer Girl Thank you! I will definitely read some of the threads. Going on vacation next week so that will be a good time to do so! Connie

@@CowgirlJane I respect your position. Many people make the choice to consume alcohol in a social manner. I have no issues with people drinking alcohol. I believe each individual needs to consider their circumstances (medical and others) and make their own choice. I believe that the medical community, however, needs to make it clear that alcohol is a toxin, can interfere with the absorption of essential nutrients, and that it is definitely nothing but empty calories.

@@VSGAnn2014 Thank you for your response! I'm not a nutritionist, or a physician, but I'll answer each of your questions from my perspective and having worked in a bariatric center for the last 12 years. But please consult your physician and nutritionist. So you're anti-alcohol of any kinds for WLS patients and think all WLS patients should be or become tee-totalers ... right? Personally, I am against alcohol for all WLS patients for the reasons mentioned in the article, including: alcohol is a toxin, it is empty calories, it is empty liquid calories, and there are potential nutritional absorption issues that could be made worse by drinking alcohol. Do you feel the same way about alcohol for patients a year out (and in maintenance) as during the weight-losing phases? Yes, for the same reasons as stated above. Do you also recommend no-Cookies for WLS patients? Ever? Even in maintenance? Recommend? Yes, I would recommend no cookies, although I wouldn't expect in reality that a person may never have a cookie again. Four cookies at a time? I would never recommend that. Unlike alcohol, however, a cookie is not a toxin that interferes with absorption of essential nutrients. What about cake? Recommend? Yes, I would recommend no cake, although I wouldn't expect in reality that a person may never have cake again. Unlike alcohol, however, cake is not a toxin that interferes with absorption of essential nutrients. Barbeque (and all the sugar in those BBQ sauces)? Chili? There are no toxins that interfere with absorption of essential nutrients in these foods. There are carbs in all foods other than lean meat, so people will eat some carbs. I do not recommend going carb-free. Breads? If not all breads, which kinds / brands? There are no toxins that interfere with absorption of essential nutrients in these foods. There are carbs in all foods other than lean meat, so people will eat some carbs. I do not recommend going carb-free. Always the healthier the better. What about coffee? Tea? Marijuana? I would ask your doctor and nutritionist about coffee and tea. I believe there are other reasons they suggest to limit these. Marijuana? No, I would not ever RECOMMEND that someone use marijuana (unless POSSIBLY in the case of medical illness). What about sweet potatoes? White potatoes? There are no toxins that interfere with absorption of essential nutrients in these foods. There are carbs in all foods other than lean meat, so people will eat some carbs. I do not recommend going carb-free. Fruits -- with or without sugar? There are no toxins that interfere with absorption of essential nutrients in these foods. There are carbs in all foods other than lean meat, so people will eat some carbs. I do not recommend going carb-free. So - those are my thoughts. Again - please consult your physician and nutritionist as those are not my areas of expertise. Be well!

Great thoughts, opinions and ideas! Thank you for sharing your experiences and beliefs. Helps us all learn and grow!

I know I said my next article was going to be on causes of obesity, but I got carried away tonight doing some investigating about the professional medical guidelines for alcohol use after weight loss surgery. In summary, the gist of the recommendations are: “Patients undergoing bariatric surgery should be screened and educated regarding alcohol intake both before and after surgery… patients should be made aware that alcohol use disorders (AUD) can occur in the long term after bariatric surgery.” (From: http://asmbs.org/resources/alcohol-use-before-and-after-bariatric-surgery.) Bariatric Realities – Medical Professionals’ Guidelines about Alcohol Use & WLS I know I said my next article was going to be on causes of obesity, but I got carried away tonight doing some investigating about the professional medical guidelines for alcohol use after weight loss surgery. In summary, the gist of the recommendations are: “Patients undergoing bariatric surgery should be screened and educated regarding alcohol intake both before and after surgery… patients should be made aware that alcohol use disorders (AUD) can occur in the long term after bariatric surgery.” (From: http://asmbs.org/resources/alcohol-use-before-and-after-bariatric-surgery.) Well, now. Those are some non-specific medical recommendations by medical professionals who are the predominant leaders and caregivers of the surgical weight loss population. Education and awareness. Hey – I am all about education and awareness. Great things, education and awareness. And yet, I’m gonna say that as a recommendation, that is a very “PC” non-recommendation recommendation, when one considers that we are talking about 1) ALCOHOL and 2) WEIGHT LOSS SURGERY patients. Consider these educational nuggets and facts I found that WLS patients really ought to be aware of: Psychologist Stanton Peele, writes, “readers now know that scientifically, it's not alcohol that causes people to live longer, but it is simply being with others and that they are less socially isolated when they drink that prolongs their lives. After all, alcohol is a toxin.” (italics and bold added) (From https://www.psychologytoday.com/blog/addiction-in-society/201011/science-is-what-society-says-it-is-alcohols-poison. My comments: Yes – alcohol is a toxin, and that means POISON. Those of us in the medical field really ought to know that people are not supposed to ingest poison. But the recommendations do not say, “Do NOT ingest the toxin, alcohol.” No, no, no… they say be educated and aware. Dr. Charles S. Lieber, M.D., M.A.C.P., in a publication for the National Institute on Alcohol Abuse and Alcoholism, writes, ““A complex interplay exists between a person’s alcohol consumption and nutritional status,” and … alcohol and its metabolism prevent the body from properly absorbing, digesting, and using essential nutrients” (italics added.) Dr. Lieber does indeed, educate us about the nutritional value of alcohol: “Alcohol would not fall under the category of an essential nutrient because not having it in your diet does not lead to any sort of deficiency. Alcoholic beverages primarily consist of water, pure alcohol (chemically known as ethanol), and variable amounts of sugars (i.e., carbohydrates); their content of other nutrients (e.g., proteins, vitamins, or minerals) is usually negligible. Because they provide almost no nutrients, alcoholic beverages are considered ‘empty calories.’ Therefore, any calories provided by alcoholic beverages are derived from the carbohydrates and alcohol they contain.” (italics added) My comments: People who have weight loss surgery (other than the band) experience absorption issues to one degree or another. Nutritional deficiency is one of the concerns the medical professionals monitor in the months and years following WLS. We stress to patients the importance of taking vitamin supplements for the rest of their lives to help ensure proper nutritional balance. And yet, rather than saying, “Alcohol use is unwise after WLS,” or “Don’t drink alcohol after WLS,” the governing body of health professionals for bariatric surgery recommends being “educated” and “aware.” Is that happening? Are the physicians and surgeons and nutritionists and mental health professionals educating patients and making patients aware that ALCOHOL IS A TOXIN THAT CAN INTERFERE WITH VITAMIN ABSORPTION – and it should not be consumed after weight loss surgery? I can’t answer that, although I know we do this at the programs I work with. If it’s not happening, why not? Having a background in direct sales, which, ironically, was incredible education for my later career as a psychologist, I was taught to “anticipate the objections.” Many health care professionals may be pooh-pooh’ing the vitamin deficiency issue associated with alcohol, stating it’s only those who drink heavily who are at risk for this type of vitamin deficiency. That information, to the best of my knowledge, is relevant for persons who have not had weight loss surgery. What’s more, we don’t know the extent to which people are drinking many years after WLS. Most of the research, as noted in the ASMBS Guidelines/Statements entitled ASMBS position statement on alcohol use before and after bariatric surgery, states, “The existing studies do not present a uniform picture regarding the overall prevalence of lifetime or current alcohol use disorders (AUD) in patients seeking bariatric surgery. The vast majority of the existing literature is retrospective, with small sample sizes, lack of control groups, and low response rates. There are also varying definitions of alcohol disorders (“high-risk” versus “misuse” versus “abuse/dependence”) in the bariatric surgery literature.” In other words, this research does provide some information, but remember, we don’t really know that much because there isn’t enough research on enough people over a long enough period of time. We don’t then, know the actual affect that alcohol use has on vitamin absorption for WLS patients. We DO know that vitamin deficiency is a concern, so WHY aren’t we telling people not to drink? Not only is alcohol a toxin for our bodies, “Alcohol is actually classified as a drug and is a known depressant. Under this category, it is the most widely used drug in the world. According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA)” (italics and underling added). http://www.medicinenet.com/alcohol_and_nutrition/article.htm My comments: I am literally chuckling now at the absurdity of this situation. The situation being the medical professionals, all having a code of ethics that reflects the “do no harm” sentiment, ignoring potential harm for their patients. Please note that we would all consider alcohol as being “empty calories” and having sugar/carbohydrates and certainly no protein. PLEASE let it be the case that the mental health practitioners around the world who deal with surgical weight loss patients are telling them, “Don’t eat empty calories. Eat a lot of protein. Limit the simple carbs and sugar. And refrain from consuming your calories from liquids. NO STARBUCKS. BUT, HEY - GO AHEAD AND DRINK THOSE SUGAR/CARB LADEN, EMPTY, NUTRITION-ROBBING TOXIC CALORIES IN ALCOHOL, THAT ARE, BY THE WAY, THE MOST WIDELY ABUSED DRUG IN THE WORLD.” Honestly, that sentence should be the entire article. But WAIT! There’s MORE! I really love this last tidbit I’ll share with you. It’s so much nicer for me when I can find it online so it’s not that mean, alcohol-hating Dr. Stapleton being the one to blame! “The truth is that no one needs alcohol to live, so regardless of what you've heard or want to believe, alcohol is not essential in our diets. Did you know that a glass of wine can have the same calories as four cookies? How about a pint of lager – surprised to hear it’s often the caloric equivalent of a slice of pizza? You do not need to be an alcoholic for alcohol to interfere with your health and life.” https://www.drinkaware.co.uk/check-the-facts/health-effects-of-alcohol/appearance/calories-in-alcohol Do you hear this, people in the medical profession? Are you giving the OK for your patients to eat four cookies “now and then,” or “in moderation,” or “not for the first six months, or year after surgery?” Do you realize that you may be DOING HARM by giving your patients “permission” to drink alcohol? “But our job is not to be the watchdog or decision-maker for people.” Another potential objection to my dismay about the recommendations being for “education” and “awareness,” rather than a direct, “SAY NO TO ALCOHOL” stance. I agree that no one can make the decisions about what people can or cannot do, or what they will or will not do. People in the medical field do tell people things like, “Don’t get that wet or you could get an infection,” “Keep the splint on for the next six weeks if you want to heal properly.” There ARE dos and don’ts that are educational and increase awareness. What’s the real issue that medical professionals don’t take a hard stance on alcohol after WLS? I don’t know. I do know that I did my dissertation on medical doctor’s attitudes toward addiction. Turns out it is much like that of their attitudes toward obesity: many don’t know that much about it, very many do not feel comfortable working with it, and most don’t care about/understand it. To top it all off, HERE’s the real kicker… Not only do the medical AND some of the WLS organizations not tell people, “Don’t drink alcohol,” THEY PROVIDE ALCOHOL AT THEIR EVENTS! I can’t say any more. Connie Stapleton, PhD connie@conniestapletonphd.com Facebook: Connie Stapleton Twitter: @cstapletonphd LinkedIn: Connie Stapleton, Ph.D.

“Why do we always talk about such ‘nice’ ways of dealing with anger? When I’m angry, I need to do something physical and not so nice!” Get that Anger OUT! In the group class I am currently leading, we have been talking about the importance of learning to identify feelings – the word that describes the feeling (mad, sad, glad, scared) AND where and how you feel it in your body (heaviness in your heart, tension in your jaw, tingling in your arms). We have also been discussing healthy ways to express and deal with feelings. A woman who I’ve known and worked with in therapy for several years has been very quiet throughout the first nine weeks of class. To my surprise, as we were talking about some of the most noted healthy ways to deal with anger (breathe deeply, set aside time to talk to the person using fair fighting techniques, talking to a friend), from the back of the room, this woman, who I will refer to as Kathy, blurts out in a healthy vocal level: “Why do we always talk about such ‘nice’ ways of dealing with anger? When I’m angry, I need to do something physical and not so nice!” Being like Kathy myself in that I have a pretty intense anger response, I laughed and told her I completely understood where she was coming from. The class offered a few helpful suggestions for dealing with anger in physical ways. I promised her that I would create a list just for her delineating healthy physical ways to deal with anger. Tonight, sitting at my favorite calming spot, the swing on my second-story deck that looks out into the sky and newly budding trees of the woods behind my house, I saw a dinosaur in the clouds. Its ribs were showing, it’s head rather distorted, and it’s tail very, very long. I thought of taking a picture for my grandkids, but my phone was upstairs charging and I didn’t want to move from my swing. Wish I had. I guess it was actually a dissipating jet stream, but I thought it was cool and remembered seeing some really cool cloud pictures recently online. I don’t know for sure what that has to do with anything, but all of a sudden I decided I needed to make Kathy’s list. I did the very scientific thing and Googled, “Healthy ways to physically express anger,” “Physical expression of anger,” “Ways to work out your anger,” etc. I found ONE little article that had four lame little suggestions. Everything else focused on… yep, the standard things - breathe deeply, set aside time to talk to the person using fair fighting techniques, and talking to a friend. Too passive for folks like Kathy and me who need to find a physical outlet when we are really ticked off and want to scream at someone. Of course, that option is just not okay (which I worked really hard to try to convince Kathy of)! Because I couldn’t find anything worthwhile on line, I sat down and to my own surprise, came up with this list in just minutes! Enjoy it. Share it with your friends (and family)! And use it!!!! Kathy’s List of Ways to Express Anger in a Physical Way that Won’t Harm Anyone 1. Scream – where no one can hear you. a. Scream into your pillow. b. Go into a closet, shut the door and scream. c. Sit in your car with the windows up and scream. d. Then get a cold glass of water and cool down. 2. Do an ANGER dance! a. Be like Goldie Hawn in Housesitter and have yourself a good old “expressive” dance! Shake what your mama gave ya! b. Jump up and down like you’re on a trampoline – and scream while you’re doing it! c. Actually jump on a trampoline if you have one handy! d. Then turn on a love song and have a good cry. 3. Exercise … yes, move your groove thing! a. Walk or run – outside or inside on the treadmill. b. Get a kickboxing DVD and kick some arse! c. Do that strenuous type of yoga – you’ll get the energy out and relax yourself all at the same time! d. Then lay on the cool floor and have a laughing fit, remembering it’s probably not so serious after all. 4. Find a dog… a. Chase it in circles… big circles, small circles… b. Play tug of war with it. c. Have a growling contest with it. d. Then, pet the little friend and you’ll feel much better! 5. Get one of those old toys that kids practice doing hair on… a. Comb the mess out of it with all your might! b. Pull that hair! c. Tell the mannequin head all about your anger. d. Then listen to what it says back to you… 6. Stand in front of the mirror… a. Tell yourself what the matter is. b. Use foul language. c. Make horrible, mean, ugly faces at yourself. d. Then laugh with yourself. 7. Have an imaginary conversation with the person or situation you’re mad at… a. Exaggerate the details so they/it sound really horrible. b. Tell them about how wonderful you. c. Remind them how valuable you are to them. d. Then find some rational thought and calm yourself down! 8. Go outside… a. Pull some weeds. b. Throw some twigs. c. Stomp some dirt. d. Then look at the clouds and find a fun shape. (Maybe that’s the connection to the dinosaur I saw in the sky.) 9. Make some angry art… a. Watercolor a dark scene. b. Draw out the situation you’re mad about. c. Write an angry poem. d. Then write yourself a love note. 10. Write the “THERAPEUTIC Letter!” a. Spill it all out on paper! (Do NOT send this letter!) b. Use red ink or red font color. c. Use whatever language feels best. d. Then thank the person or situation for the lessons you’ll eventually glean from this. Connie Stapleton, Ph.D. www.connie@conniestapletonphd.com FB: https://www.facebook.com/connie.stapleton.923 Twitter: @cstapletonphd LinkedIn: Connie Stapleton, PhD YouTube: Connie Stapleton

I’m writing this article as an invitation for each of you to help educate physicians about the issues you face related to weight loss surgery and what you believe is needed to enhance your care, either before or after weight loss surgery. The American Society for Metabolic and Bariatric Surgery (ASMBS) emails each new edition of “connect,” their official news magazine to its members upon publication. In it, they provide a synopsis of recent articles of interest related to WLS. One noted article this week is titled, “What Matters: What’s the magic behind successful bariatric patients?” and is written by Dr. Jon O. Ebbert, an internist at Mayo Clinic. In the article, Dr. Ebbert states, “I was left wondering how I can best help my patients using this information.” Let’s help him help his patients! I’ll share the short article, give my editorial (what I didn’t share with Dr. Ebbert) and then write the response I did share with him. Finally, I’ll provide the link where you, too, can share feedback directly about the article, or send it to me and I will be happy to forward it! The article: “MARCH 3, 2016 A fair number of my patients have had or are undergoing bariatric surgery. Disconcertingly, a not insignificant number of them are regaining the weight after surgery. Weight regain will occur in 20% of patients undergoing bariatric surgery after initial weight loss. When this occurs, not only do we have a patient with an altered gut putting them at risk for nutritional deficiencies if we are not fastidious in our follow-up, but they are discouraged and overweight again. Add this to the concern that bariatric surgery has been associated with an increase in suicides (2.33-3.63 per 1000 patient-years), and we may have some cause for alarm. So, what predicts success – and can we facilitate it? Several factors have been shown to predict successful weight loss after bariatric surgery. An “active coping style” (that is, planning vs. denial) and adherence to follow-up after bariatric surgery have both been shown to be associated with a higher percentage of excess weight loss. Interestingly, psychological burden and motivation have not been associated with weight loss. In a recent article, Lori Liebl, Ph.D., and her colleagues conducted a qualitative study of the experiences of adults who successfully maintained weight loss after bariatric surgery (J Clin Nurs. 2016 Feb 23. doi: 10.1111/jocn.13129). Success was defined as 50% or more of the excessive weight loss 24 months after bariatric surgery. The voice of the successful bariatric patient is an interesting and important one. Several themes were identified: 1) taking life back (“I did it for myself”); 2) a new lease on life (“There are things I can do now that I am not exhausted”); 3) the importance of social support; 4) avoiding the negative (terminating unhealthy relationships in which “food is love”); 5) the void (food addiction and sense of loss); 6) fighting food demons; 7) finding the happy weight; and 8) a ripple effect (that is, if you don’t eat it, the rest of family doesn’t, either). I was left wondering how I can best help my patients using this information. First, I think the themes can mature our empathy for the struggles that these patients face, and perhaps help us combat bias. Second, I think this knowledge can inform early discussions around what sorts of things need to be lined up for after the procedure, such as social support. Finally, I think the themes can be universalized and help us counsel patients who may be struggling with weight, but who are otherwise not candidates for bariatric surgery.” My Editorial I’m grateful that an internist is addressing the topic of WLS. I love that he is thinking about ways to use the information gleaned from the research he notes related to the behaviors of those who have “successful weight maintenance” following weight loss surgery. Pardon my sarcasm, but, WOW! Getting information about the behaviors that led to weight loss from patients who have 50% or more of excessive weight loss 24 months after bariatric surgery? Does that really tell us anything? I’d venture to say that the majority of professionals in the field would note the surgery itself as being primarily responsible for the “success” of the weight loss at 24 months out. I’m NOT saying that many patients fail to put forth a great deal of effort at that point, because I know many do work very hard during those first 24 months. But come on… let’s talk to successful weight maintainers at 5 years after surgery to get a better indication of what they are doing to manage a healthy weight. I’d also be curious to know at what point in time after surgery the statistic was obtained noting “Weight regain will occur in 20% of patients undergoing bariatric surgery after initial weight loss.” How much weight regain? After how much time? If you look closely at research in many fields, you can find numbers that vary widely on a particular topic. Dr. Ebbert states, “Psychological burden and motivation have not been associated with weight loss.” I wasn’t at all sure what this meant. Questioning my comprehension skills, I asked some other people how they interpreted that statement, and they couldn’t tell, either. If the implication is that psychological issues have no impact on weight loss or lack thereof, I have to disagree. But then, I have no research to back up my hypothesis. I do have 11 years working in this field and the anecdotal evidence of hundreds of patients that says otherwise. I’d say depression interferes with the desire/ability to follow through with certain behaviors that require significant energy. I’d say that intense shame interferes with the perceived efficacy to follow through for the long haul with behaviors necessary to sustain weight loss – well past two years of having WLS. I don’t know… I believe poor self-esteem, a history of “failing” with “diets,” unresolved grief, loss, and abuse issues sometimes affect a person’s perceived ability to succeed. I also believe treating these psychological issues in conjunction with treating one’s physiology and teaching important skills such as healthy coping mechanisms, positive self-talk, and efficacy-enhancing skills is a recipe for better outcomes. My Response to Dr. Ebbert (in an attempt to be brief): “Dr. Ebbert - With all due respect, the medical field is, in my opinion, missing several very large pieces of the puzzle with the surgical weight loss population in terms of treating them. I am a licensed clinical psychologist. I work in a surgical weight loss clinic and have spoken with literally thousands of patients who have had weight loss surgery. Obesity is a complicated disease that is more than just physiological. I treat the underlying and associated psychological co-morbidities, which the medical community largely ignores, except under the broad category of "Behavior Modification." I assure you that there is a lot more than changing behaviors that needs to be addressed with this population. A vast majority of this population suffers with deep shame and low self-esteem, both rendering them inefficient at maintaining motivation to follow through on a long-term basis with "behavior modification." I am working tirelessly to try to address the elephants in the OR, but surgeons don't really want to listen to myself - or the patients - who are clamoring for additional mental health care (MORE than behavior modification) following WLS when their "issues" interfere with healthy behaviors - just like before surgery. More suicides? Maybe because in a sense, we take away the patients’ coping skill (food) and throw them to the wolves. I've created a video series that I require all of my patients to watch before surgery to help them understand the deeper issues they may face and to urge them to seek counseling. I could use help in the medical community. You in?” I do believe, and I thank Dr. Ebbert for noting, “this knowledge can inform early discussions around what sorts of things need to be lined up for after the procedure.” Let’s all pitch in and share with Dr. Ebbert and other interested physicians what you need to be successful, on and off the scale, for years and years following WLS. Please share your comments at: http://www.clinicalendocrinologynews.com/comments/what-matters-whats-the-magic-behind-successful-bariatric-patients/016f71fe2abdc0198ac42d75d039d712.html?comments_link=1 Or, post your comments here or contact me via my web page: www.conniestapletonphd.com Let’s pitch in and help! Connie Stapleton, Ph.D.

Bariatric Realities I’m doing this series called “Bariatric Realities” as a result of many frustrations. In this case, the energy generated in my body and brain, as a result of these annoyances, is my motivation for developing this series. I need to “get it out,” put my thoughts and feelings on paper - and on video - and share them. I want to talk about what I see and hear, day in and day out, from the patients I work with. These vulnerable men and women tell me about the realities of dealing with weight issues, the struggles related to getting extra weight off and keeping it off, and the underlying emotional hurdles interfering with their progress. Bariatric Realities I’m doing this series called “Bariatric Realities” as a result of many frustrations. In this case, the energy generated in my body and brain, as a result of these annoyances, is my motivation for developing this series. I need to “get it out,” put my thoughts and feelings on paper - and on video - and share them. I want to talk about what I see and hear, day in and day out, from the patients I work with. These vulnerable men and women tell me about the realities of dealing with weight issues, the struggles related to getting extra weight off and keeping it off, and the underlying emotional hurdles interfering with their progress. I’m frustrated that patients, whether they are seeking medical weight loss assistance or opting for weight loss surgery, are given only part of the story and only part of the solution. The emphasis in all bariatric programs, obviously, is on meal planning and “behavior modification.” These are, of course, essential elements of weight loss and healthy weight management, but they are only part of the deal. The emotional components related to weight issues – shame, self-esteem, body image, family of origin issues, past trauma, relationship changes following weight loss – these and many other crucial, emotional/psychological issues are so often ignored. Not to me, they aren’t. And these will be addressed in this series. In addition, I want to inform other professionals in the medical, psychological and psychiatric fields about things patients (and, to be fair, some professionals) know, but the scholarly types won’t listen to, because what I have to say isn’t “evidence based.” Meaning there are no formal research studies or statistics to verify or validate what I, and so many others, know to be true. Oh, I am a believer in, and supporter of evidence based research – without a doubt! And yet, so many topics that need to be addressed in the area of weight loss have not been formally researched, nor do they always lend themselves to scientific investigation. (Not to mention, the evidence found in evidence-based research is very often conflicting and ever changing. That, however is another paper…) I will address those very real problems related to weight loss and maintenance that are largely ignored due to a lack of research-based evidence. And yet, those topics are so very, very real. Here’s a sneak peak at the types of things I’ll be addressing in the Bariatric Reality series. Alcohol Use After WLS This topic is widely debated by patients and professionals alike. It is, indeed, discussed at the professional meetings. In fact, just a few years ago, a big fuss was made at one of the largest bariatric surgery professional meetings about brand new research related to Alcohol Use Disorders following weight loss surgery. The actual researchers presented findings of their newly published data recently released in The Journal of The American Medical Association (JAMA): Prevalence of Alcohol Use Disorders Before and After Bariatric Surgery. The authors reported a 2% increase in Alcohol Use Disorders at the 2-year post-surgical assessment. Is this information helpful? Of course it is! Does it tell much of a story, really? If you ask those of us who work day in and day out in surgical weight loss programs, I’d venture to say that the majority would report that this 2% statistic at two years post-op doesn’t even begin to tell the reality of the problems we see with “Alcohol Use Disorders” following weight loss surgery… some a year after, some two years after, some five years after. And it’s not just alcohol. It’s also abuse of pain medications, spending, promiscuous sexual behavior and eating disorders. And tell me… how many WLS patients who have “Alcohol Use Disorders” haven’t returned to their bariatric centers for follow up to be included in the research results? How many haven’t mentioned anything about “Alcohol Use Disorders” to the multidisciplinary team? A lot. Yet we can’t present the very real information from patients who tell us about their friends who won’t come see the doctor after their surgery … the ones they are worried about because the person of concern isn’t eating but is consuming the majority of their calories from alcohol. We can’t count, or report on, the patients whose won’t come in for a follow-up and who drink so much they are falling down and hurting themselves. There is no “data” to indicate the number of patients calling and insisting they need more or higher doses of pain medication and become hostile or abusive to the staff when told the doctor won’t prescribe any more. We don’t have “numbers” for the patients who sit in my office and cry because they are sleeping with anyone who shows any interest in them. We have no data on the number of patients who tell me and other providers around the country that they meet strangers at motels for sex, something they never did before. How do we help educate other professionals about very real, very dangerous “anecdotal” reports of problems, when, alas, we have no DATA? No, this type of information is not discussed at the “professional” meetings because we don’t have scientific evidence. But these things are happening. They are real. And they need to be talked about. So I’ll talk about them and hope someone listens. A lot of someones – so that people won’t be afraid to ask for help for these issues, knowing they’re not alone. And so that professionals may – just may – stop pretending these things aren’t happening because there are no “numbers” to support the reality. Food Addiction Last year, I spoke at a national weight loss conference for overweight and obese patients. The moderator of the panel of which I was a part, felt strongly that food/eating is not an addiction. He therefore posed this question to the audience of approximately 200 people: “How many of you consider yourself to be a food addict?” Nearly every hand in the audience shot up immediately. I explained to him, and to the audience, that the hallmark of addiction is knowing something is a problem and has caused problems (think of all the health-related problems associated with obesity), wanting to stop (wanting to lose weight) having made many attempts to stop (consider all of the prior dieting), but not being able to stop (most people regain any lost weight from dieting and feel hopeless about being able to make permanent changes to their eating and exercise behavior). These people who consider themselves food addicts are addicted to food/eating, physically and/or emotionally. They know their weight is causing serious problems in their lives, they want to stop, but they cannot. That’s addiction. “Where’s the evidence, Connie?” Well, I don’t have it. And I can’t find that many others do, either. I did find a “scholarly article” from 2013 of a study of 652 adults from the general population in Newfoundland, in which the prevalence of “food addiction” was 5.4%. The majority of other “scholarly articles” that even discuss food addition focus primarily on Binge Eating Disorder or the “neurobiology” of food addiction. Often the conclusions are similar: professionals differ on their beliefs about the idea of whether or not “food addiction” is real. Ask your patients. They believe food addiction is real. So if, at the professional meetings, we can only discuss food addiction based on the “research,” it seems we are limited to debating the existence of food addiction, or to sharing the percentage of “food addicts” in Newfoundland. How, then, are we supposed to talk to professionals about the myriad of non-scientifically-researched REAL issues that patients experience in their REAL lives? I’m frustrated. Bariatric Realities is my new outlet. I will talk in REAL language about the REAL issues experienced by the REAL patients I work with all day long. I hope it will get others talking! Share your REAL thoughts, feelings and observations with me and other readers! THANKS! The NEXT TOPIC for Bariatric Realities: Genetics and Sources of Weight Problems – What ARE You Accountable for? Connie Stapleton, PhD connie@conniestapletonphd.com Facebook: Connie Stapleton Twitter: @cstapletonphd LinkedIn: Connie Stapleton, PhD

I got a text this week from a former client who moved out of the state a while back. This woman, who I will call Mattie, had weight loss surgery four years ago. She lost the majority of her excess weight and has maintained that weight loss. She’s even had a baby and continues to maintain her weight loss! Mattie asked me a few questions. We exchanged a few texts before I told her I would send her an email with some thoughts. I was actually on the treadmill at the time and haven’t quite mastered accurate texting while hustling on the treadmill (and watching my guilty pleasure, The Young and The Restless) while I walk! Here’s how our messages went... I got a text this week from a former client who moved out of the state a while back. This woman, who I will call Mattie, had weight loss surgery four years ago. She lost the majority of her excess weight and has maintained that weight loss. She’s even had a baby and continues to maintain her weight loss! Mattie asked me a few questions. We exchanged a few texts before I told her I would send her an email with some thoughts. I was actually on the treadmill at the time and haven’t quite mastered accurate texting while hustling on the treadmill (and watching my guilty pleasure, The Young and The Restless) while I walk! Here’s how our messages went: Mattie: “I want your professional opinion… Orthorexia nervosa and body dysmorphia… real or not real?” I honestly had never heard of orthorexia nervosa, so, while contemplating whether or not I like the new actor playing Billy Abbot, I looked up orthorexia nervosa. Here’s the definition from the National Eating Disorders Association (https://www.nationaleatingdisorders.org/orthorexia-nervosa): “Those who have an “unhealthy obsession” with otherwise healthy eating may be suffering from “orthorexia nervosa,” a term which literally means “fixation on righteous eating.” Orthorexia starts out as an innocent attempt to eat more healthfully, but orthorexics become fixated on food quality and purity. They become consumed with what and how much to eat, and how to deal with “slip-ups.” An iron-clad will is needed to maintain this rigid eating style. Every day is a chance to eat right, be “good,” rise above others in dietary prowess, and self-punish if temptation wins (usually through stricter eating, fasts and exercise). Self-esteem becomes wrapped up in the purity of orthorexics’ diet and they sometimes feel superior to others, especially in regard to food intake. Body dysmorphia, just to get the formal definitions over with, is a clinical diagnosis in the Diagnostic and Statistical Manual (DSM V), the guidebook used by psychiatrists, psychologists, and other health care professionals. People who have Body Dysmorphic Disorder are: “preoccupied with one or more nonexistent or slight defects or flaws in their physical appearance.” Keep in mind that the emphasis is on nonexistent or slight defects, not something that is clearly visible. “‘Preoccupation’ is usually operationalized as thinking about the perceived defects for at least an hour a day… The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” “At some point, the individual must perform repetitive, compulsive behaviors in response to the appearance concerns. These compulsions can be behavioral and thus observed by others – for example, mirror checking, excessive grooming, skin picking, reassurance seeking, or clothes changing. Other BDD compulsions are mental acts – such as comparing one’s appearance with that of other people.” Now that you know what we’re talking about, I’ll continue with our text conversation. In response to Mattie’s question about whether or not orthorexia nervosa and body dysmorphia are real, I responded: “Yes, real.” Mattie: “Thank you.” Me: J J J J Mattie: “I’ve been doing a lot of research on eating disorders and the psychological issues that come with them when I came across these. Me: Do you think you have those issues? Mattie: I don’t know. I think I may but I feel crazy saying that. I need to do some more research to know for sure but from everything I’m reading it describes me pretty well. I seem to have gone to the opposite extreme from where I was three years ago. Me: That means you haven’t dealt with the issues but are acting them out on the other end of the spectrum. Mattie: That’s what I’m scared of. Me: Yeah, but you would not be exploring it if you weren’t willing to work on things. Mattie: Very true. I just feel like it’s all in my head but then again, not. It’s deeper than just my thoughts. It’s almost like these other little voices outside of myself telling me what to think and how to act. Me: What are the voices saying and whose voices are you hearing? Mattie: They are mine and the voices of lots of other people I have known throughout my whole life. Most of the time they are just telling me whatever I do isn’t good enough and that I have to do more. No matter what, don’t mess up because it’s impossible to undo. All my flaws are being pointed out along with the mistakes I make and how much I still need to do. Last week I had a full-blown panic attack because I ate some rice with my meal and felt like I could feel it going through my system and turning into fatter things and a big old stomach. After I finally calmed down I ended up at the gym doing cardio for 2 ½ hours. Stuff like that happens more than I care to admit. Sometimes when I think about it I freak out so much I actually get sick. All of this makes me wonder if the surgery wasn’t the result of my brain saying ‘you should do this because it will make you prettier and healthier.’” Me: I’ll email you… too much to say and I’m on the treadmill. I also didn’t want to miss finding out if Billy was in cahoots with Phyllis or if he was backing out of their deal… The more I thought about all I wanted to say to Mattie, the more I decided others would benefit from the information. I’m certain she’s not the only one struggling with many of the issues she brought up. To begin with, a great many people who have weight loss surgery find themselves engaging in behaviors that are unhealthy two to three years later. I’ve worked with patients who start drinking excessively, shopping themselves into financial distress, sleeping with people they don’t even want to be sleeping with, abusing/becoming dependent on pain medication, returning to unhealthy eating behaviors and starting to regain weight, spending too many hours exercising, behaving in other forms of bulimic behavior, engaging in anorexic behavior, and, I now learn from Mattie, orthorexia nervosa. It’s fairly predictable. For the first year to 18 months, people are thrilled because they are losing the weight they struggled to shed for so long. It’s exhilarating to see the results they so longed for. It is an exciting time and the body is doing what it is supposed to do following the surgery. As the body heals and weight stabilizes, sometimes people begin to engage in behaviors they may not even understand themselves. So what is the explanation for a return to eating unhealthy food in spite of knowing the misery of having been morbidly obese and experiencing significant health issues as a result? What sense does it make to become anorexic or orthorexic or alcoholic or a shopaholic or to engage in any sort of behavior to the point it creates problems in your life? To mental health professionals, it makes perfect sense. We understand that for many people who struggle with weight issues, there is emotional baggage beneath the surface. Weight loss surgery doesn’t treat “head issues.” When people have weight loss surgery, they lose the option (at least for a time) to use food as a coping mechanism, an attempt to avoid dealing with things that are under the surface. Mattie was quick to point out what is at the heart of the real problems, the issues underlying one’s weight and focus on food… it’s the voices of various people from your past who have told you things similar to what Mattie continues to hear in her head: You could have done better. You could have done more. You got all A’s but one B… why wasn’t that an A? Why can’t you be more like your sister? If you keep gaining weight, no one will marry you. You’ll never amount to anything. It’ll just never be ‘good enough.’ Mattie made it clear that it’s not just the voices of others she hears, but also her own. There’s a simple reason for this: Children learn what they live…and then they live what they learned. The negative messages you heard about yourself from others as you were growing up are what you learned as you grew up. Every time you repeat those messages to yourself in the present, you are living what you learned. As an adult, you’re reinforcing to yourself the negative things you initially heard from others about you. The solution? Simple – yet very difficult! You have to make a commitment to yourself to no longer talk to yourself about yourself in negative terms. Even if you don’t believe yourself at first. And you have to put a lot of effort into changing and restating the negative messages you repeat about yourself so they are at least neutral: · You could have done better. o When you hear this message, change it to, “Maybe I could have done better, and yet I can’t change the outcome of this situation. I’ll think about what more I might be able to do the next time this situation arises.” · You could have done more. o When you hear this message, change it to, “There’s probably always more that could be done in a given situation. That’s as much effort as I was willing to put into this situation at this time.” · You got all A’s but one B… why wasn’t that an A? o When you hear this message, change it to, “Perfection doesn’t exist, nor did I want to put forth the effort for that particular endeavor. I’m pleased with the results.” · Why can’t you be more like your sister? o When you hear this message, change it to, “I can’t be more like her because we are different people and I’m learning to like myself just fine.” · If you keep gaining weight, no one will marry you. o When you hear this message, change it to, “I’m learning to accept myself the way I am and I don’t want to marry or have close relationships with anyone who doesn’t accept me as I am.” · You’ll never amount to anything. o When you hear this message, change it to, “Never amount to anything according to whom? I’m becoming more and more comfortable with who I am and what I want in life. That’s what matters.” · It’ll just never be ‘good enough.’ o When you hear this message, change it to, “I’ve come to terms that I am, indeed, ‘good enough,’ and I like myself this way.” What makes this different is that people say, “I tried, but it doesn’t work.” Well, keep trying. The reality is you are battling years of negative messages and your brain has literally developed neural pathways so you slip back into those well-worn paths quite easily. In order to develop new neural pathways that are more optimistic toward self, it will also take thousands of repetitions. If you were learning to speak a completely foreign language, it would take days and weeks and months of repetition before the new language would come easily. It’s the same thing with positive self-talk. The good news is, you can benefit from positive changes as soon as you start talking better about yourself. Remember, no one is putting you down at this point in your life except you. (If there are others degrading you, then you need to learn healthy boundaries and tell those people to stop and/or get them out of your life.) The negative self-talk is part of the deal and changing that is a huge part of the solution. But, WAIT – there’s MORE! Of course there is! There’s actually a lot more, but this is supposed to be a short article, which it already isn’t. Therefore, I will only address one more essential issue related to weight regain and/or the transfer to another unhealthy behavior after weight loss surgery. In Mattie’s case, the transfer has been to a rigid attitude about eating healthy foods, feeling tremendously guilty if she eats anything but healthy foods, followed up by a form of bulimia known as exercise bulimia, as evidenced by her working out for 2 ½ hours after eating some rice. Regardless of what unhealthy behavior a person switches to following weight loss surgery, what needs to be addressed is the purpose the behavior serves. This points, also, to looking at what purpose food and/or obesity served prior to weight loss surgery. Simply stated, an almost obsessive focus on food, whether that is thinking about what one is going to eat next, pouring over recipes, relentless counting of calories and grams, watching every show on the Food Network, exercising excessively, obsessing about healthy foods, is a coping skill. In the adult world, people are capable of learning and understanding that these eating and food-related behaviors are unhealthy in that they negatively affect health and relationships. The reasons people remain engaged in these negative behaviors, in spite of knowing they are detrimental to their physical, emotional and relational health include the possibilities that: 1) they have addictions (to food, or other substances/behaviors), and weight loss surgery does NOT treat food addiction, 2) they are tremendously afraid of feeling their own feelings and are terrified of dealing with past emotional issues; what’s more, people often deny having any past issues they need to deal with in the first place. Trust me… we all do. Every human being has had some painful experiences in their lives. People are terrified of what I call cleaning out their emotional closets because they literally fear experiencing feelings. Here’s why: when people experience feelings from past losses and hurts, they feel it with the same intensity at which they felt it at the age they were when it happened. That frightens adults and they avoid dealing with their past at all costs. And these costs can be high; anyone who has had weight loss surgery understands the physical and emotional costs that being obese bears. Here’s the deal: if people don’t dig into whatever they are avoiding emotionally, or address any addictions head on, and if they don’t learn healthy adult coping skills, communication skills, and how to set healthy boundaries, then they WILL switch to another unhealthy behavior to use a coping skill (another name for avoiding reality and feelings). In Mattie’s case, she swung to the opposite end of the eating continuum. Either end of an issue often means the person is just acting out the same unhealthy coping skill in the opposite way. You often hear of people who are not at all religious becoming overly immersed in a religion. Same problems… just acting them out in opposite ways. Hence, my response to Mattie as she described “having gone to the opposite extreme” with her eating behavior, when I said, “That means you haven’t dealt with the issues but are acting them out on the other end of the spectrum.” My suggestion to Mattie and to anyone else who is engaging in any disordered eating behaviors, anyone who has regained weight, and anyone who has begun engaging in other addictive or unhealthy behaviors following weight loss surgery: Get into individual and/or group therapy with a therapist who understands “family systems” counseling and/or addiction counseling. Talk about issues underlying your addiction to food (your emotional dependency on food), any losses you experienced throughout your life that you haven’t dealt with, and any trauma/abuse you have experienced at any time in your life. Work with a therapist to learn and develop healthy coping skills to implement into your adult life, how to implement healthy boundaries in your adult life, with yourself and with others, and learn healthy communication skills. Read about these same topics, and add to the reading list the topic of “re-parenting the self.” Orthorexia nervosa and body dysmorphia are real, as are bulimia and food addiction and transfer addiction. Weight loss surgery can inadvertently open the door for these problematic behaviors. Do what I always tell people to do: Get Help and Get Happier! Thank you, Mattie for bringing these topics up to me. I hope this has helped you and many others! Oh – and by the way, I’ve decided I like the new Billy Abbot… so far! Connie Stapleton, Ph.D. www.connie@conniestapletonphd.com FB: https://www.facebook.com/connie.stapleton.923 Twitter: @cstapletonphd LinkedIn: Connie Stapleton, PhD YouTube: Connie Stapleton

Quit dancing around the subject and start using the STAPLE ingredient in the Recipe for Recovery: COMMITMENT. If you're guilty of doing the RECOVERY HOKEY POKEY, it's time to put your WHOLE SELF IN! The Recovery Hokey Pokey You put your right thigh in. You put your right thigh out. You put your right thigh in… and it jiggles all about… You do recovery hokey pokey and it turns you inside out Yhat’s what it’s all about! Weight loss. There’s simply nothing like it. The pounds come off. You feel great. People notice how much “better” you look. The scale is showing numbers you haven’t seen since high school. And then…it stops. Everything stops. The great feeing…the compliments…the scale. Maybe this “losing weight” thing isn’t all it’s cracked up to be after all. What happens when all the excitement fades? What happens to the motivation? What happens to that “high” you felt when you jumped out of bed to greet the day each morning at the beginning of the weight loss adventure? What happens to the excitement of doing exercises you’ve never been able to do before? Oh – reality! Yes, reality and the ordinariness of life sets in and now you don’t feel so inspired to do the things you need to do to get what you say you want. You know – improved health and a better quality of life. Those are the reasons most people (initially) state as their reasons for having weight loss surgery. “I don’t think I’ll work out today because…I’m tired and deserve to sleep-in.” “Maybe I’ll workout tonight, after work, when the kids are asleep.” “Gosh! I had a long day, and the kids are down…maybe I should get some sleep while I can. I’ll exercise in the morning.” “You know, I haven’t eaten anything ‘bad’ in a long time; I ‘deserve’ a little treat for all of my hard work. I’ll just have a little bowl of something sweet.” “I’m really hungry. Maybe I’ll just eat the other half.” “Who brought the donuts? I wonder if there’s a “plain” one in there…that wouldn’t be so bad.” Sound familiar? Your enthusiasm wanes, then your motivation flies out the window, and whammo! You’ve lost enthusiasm for the commitment you made to your healthy recovery. What happened? What is commitment, anyway? A commitment is a promise you make to yourself to do something or to be loyal to someone or something. We love the definition of commitment from Urban Dictionary: “Commitment is what transforms the promise into reality. It is the words that speak boldly of your intentions. And the actions which speak louder than the words. It is making the time when there is none. Coming through time after time after time, year after year after year. Commitment is the stuff character is made of; The power to change the face of things. It is the daily triumph of integrity over skepticism.” by Ashbash January 13, 2005 Your commitment to living a healthy lifestyle can be a promise you make to yourself, to your children, or to your entire family. Commitments that you write down and share with others are more likely to be maintained. Stating your commitment to your healthy lifestyle every day (out loud is best) will remind you of the promises you made to follow through with the behaviors that result in improved health and a better quality of life – the reasons you chose to have weight loss surgery. SO – when you wake up each morning, maybe sing this version of the Recovery Hokey Pokey: I put my whole self in. I put my old habits out. I put my best effort in… And I get good results out! I stop recovery hokey pokey – And I get rid of all self-doubt! THAT’s what it’s all about! Are you singing the Blues or Happy Days in your Recovery? Tune into the June APODCast on June 17, and you just might hear The Doc might sing The Recovery Hokey Pokey.

Attitudes come in all sorts of “flavors,” including the obvious, of course: a positive attitude or a negative attitude. Some attitudes might be considered rather bland: cooperative, compliant and tolerant. What flavor is your attitude? Are you complacent, entitled, enthusiastic, apathetic, grateful, superior, confident, hostile, cautious, suspicious, inferior, sincere, persistent, flexible, decisive, humble, jealous, judgmental, courteous, competitive, gloomy, sarcastic, sympathetic, cynical, critical, caring, earnest, jovial, hopeful? How important has your attitude been to your journey in your Recovery From Obesity? Recovery from obesity is both a set of behaviors and a mindset (ATTITUDE) about your health, your sense of self worth, and your willingness to do what it takes to have the health you want and to feel about yourself the way you want to feel about yourself. ATTITUDE IS THE FLAVORFUL INGREDIENT IN THE RECIPE FOR RECOVERY and it makes all the difference in how you approach your Recovery from Obesity. Your ATTITUDE also influences how you choose to use the other ingredients in the Recipe for Recovery: Awareness, Acceptance, Commitment, Accountability and Effort Attitudes come in all sorts of “flavors,” including the obvious, of course: a positive attitude or a negative attitude. Some attitudes might be considered rather bland: cooperative, compliant and tolerant. These are desirable attitudes, in most cases, and yet some people may not consider them to be very flavorful. On the other hand, a sassy attitude, an exuberant attitude, and a highly determined attitude may be considered a bit more “flavorful.” In some Zumba classes, the instructor encourages participants to add some personal “flavor” to their moves! What flavor is your attitude? Are you complacent, entitled, enthusiastic, apathetic, grateful, superior, confident, hostile, cautious, suspicious, inferior, sincere, persistent, flexible, decisive, humble, jealous, judgmental, courteous, competitive, gloomy, sarcastic, sympathetic, cynical, critical, caring, earnest, jovial, hopeful? How important has your attitude been to your journey in your Recovery From Obesity? Recovery from obesity is both a set of behaviors and a mindset (ATTITUDE) about your health, your sense of self worth, and your willingness to do what it takes to have the health you want and to feel about yourself the way you want to feel about yourself. Attitude is the FLAVORFUL ingredient in A Post Op & A Doc’s RECIPE for Recovery from Obesity. You choose your attitude throughout the day and your attitude most certainly can add flavor to any given moment, whether that is specifically related to the food/weight loss aspects of your Recovery from Obesity or the non-food aspects of your Recovery. Examples of attitude and food/weight aspects of Recovery from Obesity: SCENARIO 1: The boss brings pizza, hot dogs, chips, brownies and every variety of sugary drink you can imagine for a Memorial Day office picnic. You choose the flavor or your attitude (keeping in mind what your behavior will likely be in response to the flavor of your attitude)! A HOSTILE Attitude: “What a jerk, bringing in all kinds of junk food. Doesn’t she care about the health of her employees? And look at them…they know I’m not supposed to have that kind of crap and yet they bring their plates heaped with food with them to chat with me. How rude!” A DECISIVE Attitude: “Okay, so it's not the kind of picnic I like to attend these days, but it doesn’t matter what food is served. Anywhere I go, I am prepared with a protein bar and a protein drink. I’m glad for the camaraderie with my co-workers! And I’ll be grateful for feeling good about my choices!" SCENARIO 2: You are scheduled to meet your personal trainer in 30 minutes. You are comfortably settled in on your couch watching a favorite TV program when you notice the time and realize you need to get moving in order to be there on time. You choose the flavor or your attitude (keeping in mind what your behavior will likely be in response to the flavor of your attitude)! A COMPLACENT Attitude: “Ah… I’ve already paid for the sessions. I can skip one. I’ll let him know I’m not gonna make it tonight. He’ll probably be glad to get to go home early.” An ENTHUSIASTIC Attitude: “You know what? It might be nice to stay home and relax tonight but I made up my mind to get and STAY healthier. Exercise is part of the Recipe for Success, so I’m gonna get moving so I’m there on time.” An ENTHUSIASTIC Attitude: “Well! It might be nice to stay home and relax tonight but I made up my mind to get and STAY healthier. Exercise is part of the Recipe for Success, so I’m gonna get moving so I’m there on time.” Examples of attitude and non-food aspects of Recovery from Obesity: SCENARIO 1: Your sister-in-law, herself overweight, continues to make negative comments about your appearance since you’ve lost weight. A JUDGMENTAL Attitude: You think to yourself, “You just want me to feel bad so I regain some weight. You want me to feel badly about myself because you feel badly about yourself.” A HUMBLE Attitude: You think to yourself, “I feel sad listening to her make comments about my appearance. Before I lost weight, I would do that to others who had lost weight. It sure didn’t make me feel better and it doesn’t look like this is making her feel any better. I’ll talk to her about it later when all these people aren’t around.” SCENARIO 2: A close friend sits you down to share her observations with you. She tells you she is worried about you because you seem to be seeking attention in sexually inappropriate ways since you’ve lost so much weight. She is kind and compassionate as she shares this with you. A GRATEFUL Attitude: You thank her for sharing her observations with you, admitting you were enjoying some flirtatious attention but concerned that you might be giving messages you don’t intend to send. A CRITICAL Attitude. You tell her you know that she is saying those things to you because she is jealous that you are getting attention that she obviously wants. Just a thought: in all of the examples above, all of the negative attitudes were “A” and the positive attitudes were “B.” Perhaps consider switching these two. • • • ATTITUDE makes all the difference in how you approach your Recovery from Obesity. Your ATTITUDE also influences how you choose to use the other ingredients in the Recipe for Recovery: Awareness, Acceptance, Commitment, Accountability and Effort. Ultimately, your ATTITUDE has a large impact on your long-term success in managing a healthy weight and in how you approach life! It’s your choice as to how to use the ingredients in the Recipe for Recovery! Choose wisely!

Recovery from Obesity is a choice and, while your Recovery is unique, the ingredients in the Recipe for Recovery are not. What that means is, you determine what matters most in your life and then choose HOW to use the ingredients (Awareness, Acceptance, Commitment, Attitude, Accountability, and Effort) to live fully. Before we get much further, let’s explain what we mean by “Recovery from Obesity.” Is Recovery from Obesity… …being skinny? No. .,..a number on the scale? No. …being cured and never having to worry about weight again? No. Is Recovery improved health and quality of life? Yes. Recovery from Obesity is learning to live life on life’s terms by making the next wise choice one day at a time. Recovery from Obesity is following the Recipe for Recovery to live FULLY and become your healthiest physical, mental, emotional and spiritual self. You choose HOW to use the ingredients in the Recipe for Recovery to create your own healthy life! Recovery is a mindset, so it’s up to you to come to terms with the good, the bad and the ugly! THE POST-OP: My Recovery journey began when I lost weight (the good), but stalled when I came face-to-face with the realities of the disease of obesity and my compulsive overeating (the bad and the ugly). I wanted to be cured of obesity and hoped surgery would do the trick. I wanted to be “normal” and didn’t want to worry about gaining weight again. I quickly learned that there is no such thing as “normal” and had to decide whether I wanted to spend my life worrying about gaining weight, or managing my obesity. The choice was mine, and I chose Recovery, starting with AWARENESS of my disease. Since then, I have had to ACCEPT some difficult realities. Here are a few of the things I’ve learned to ACCEPT about myself: I ACCEPT that I do not have an “OFF” switch around certain foods. Once I start, I won’t stop until I am sick or run out of food. Therefore, I ACCEPT that those foods are off limits for me. Period. I ACCEPT that I have shrinkles on my belly, butt and legs. Needless to say, I choose not to wear a bikini. I ACCEPT that I cannot take anti-inflammatory meds (NSAIDs) to treat my joint pain because I had weight loss surgery and am prone to ulcers. I ACCEPT that I am susceptible to anemia and vitamin deficiency and must be vigilant about taking my iron and supplements. I ACCEPT that I don’t like to workout, but I know I have to if I want to be healthy. That’s the short list of stuff I had to come to terms with (ACCEPT) if I wanted what I said I wanted in my life – to live fully, free from the unhealthy obsession with food and weight. Of course, these are just “physical” things. Doc, what about the mental and emotional realities in Recovery? THE DOC: As Cari very often says, obesity is “all about the food but is not about the food.” Clearly, food is part of the problem when one is obese, and yet, obesity is so much more than just the food. For example, some people are “emotional eaters,” turning to food when they are upset, angry, bored, worried, etc. They eat in response to feelings. In this case, it’s not really about the food. Learning to deal with emotions in healthy ways is the issue! If you are an emotional eater, then choose to ACCEPT the following: ACCEPT that food is an unhealthy way to cope with feelings. ACCEPT that you may need to learn about healthy coping skills via reading books and articles or, you may need to attend therapy. ACCEPT that there may be unresolved issues related to the learned behavior of turning to food as a coping skill and ACCEPT that in order to live fully in Recovery from Obesity you will need to address those underlying issues. Relationships often change after a person loses a significant amount of weight. It can be difficult for both people in a relationship to deal with their thoughts and feelings related to the changes that seem to be brought about by weight loss. If you are struggling with relationships after losing weight, whether they are marital, friendship or family relationships: ACCEPT that changes in relationships are common after weight loss. ACCEPT that the changes need to be addressed openly and directly, that feelings need to be acknowledged and discussed, and that wants and needs change for people. ACCEPT that sometimes people need help from a professional to get through periods of significant change in relationships. “Self” often changes after weight loss surgery… self-esteem, self-image, and self-efficacy. Along with the changes in “self”: ACCEPT that these changes can affect one in positive ways and in potentially unhealthy ways. ACCEPT that others may accept or reject the changes, may celebrate or dismiss the changes, may change with your or may choose not to change. ACCEPT that you may feel uncomfortable with the changes as your body and mind adjust to them. People sometimes report being disillusioned about not being “happy” after losing weight, which they expected they would be. If this is the case for you: ACCEPT that “happiness” is an inside job and not based solely on your weight, size, appearance. ACCEPT that there are other aspects of yourself to explore including your personality traits, your talents, your interests, your behavior toward self and others. ACCEPT that “happiness” is closely related to your thoughts, then examine your thought patterns and ACCEPT that only YOU can choose if they will be positive or not! Obviously, we could write for days about how ACCEPTANCE of the “good, the bad and the ugly” is a necessary part of Recovery from Obesity. What do you need to ACCEPT in order to move closer to obtaining those things related to obesity that are the most meaningful to you? What do you need to ACCEPT that is directly about the food and what do you need to ACCEPT that is not directly related to food, but does affect your eating and exercise habits? Stick with the winners, get outside help when you need to, stay open-minded, use the ingredients of the Recipe for Recovery to live the healthy life you want…AND, be sure to join us daily on our Facebook page for ongoing motivation, education and inspiration. You can’t do this alone, and no one can do it for you!

It’s not about the food, but it’s all about the food. Wait a minute -- if it’s not about the food, then why do we (the Post-Op & the Doc) keep talking about the RECIPE for Recovery? Don’t recipes involve food? Not always… Think about it: Don’t you have a recipe for success? How about a recipe for the perfect day? …A recipe for family fun? …A recipe for a natural spot remover? …A recipe for composting? What the…composting?! Remember, the Post-Op is from Southern California, where recycling is the law. Well – you may or may not be into recycling, but we’re pretty sure you’re into living fully. If you really want to live fully during and after the process of weight loss, then the RECIPE FOR RECOVERY is something you need! Over the course of the year, we are looking at ways you can combine the ingredients for the recipe (AWARENESS, ACCEPTANCE, COMMITMENT, ATTITUDE, ACCOUNTABILITY, and EFFORT) to create your very own, personal, healthy life in RECOVERY – from…whatever (obesity, unhealthy relationships, habits, and behaviors)! In last month’s article (Six Simple Ingredients to Get the Weight Off and Keep it Off) we introduced you to each of the ingredients in the RECIPE, and briefly discussed the how each is required to live fully in Recovery From Obesity. This month is all about the “essential” ingredient: AWARENESS. We refer to awareness as being “essential” because you have to become aware of problems (food and non-food related) needing attention in order to work on them…which can be tricky… After all, some things we are aware of and some things we might not be… AWARENESS of things we don’t like A food-related example: eating simple carbs usually results in weight gain [*]AWARENESS of things we may be powerless to stop A food-related example: what other people serve in their homes when we’re invited to a large dinner party A non-food-related example: how others react to our weight loss [*]AWARENESS of things that are scary A food-related example: knowing that many holidays mean tempting foods will be prevalent in the media, at work, etc. A non-food-related example: experiencing the feelings that accompany significant weight loss [*]AWARENESS of things that seem overwhelming A food-related example: avoiding unhealthy “treats” in the work break room A non-food-related example: beginning and maintaining a regular exercise program Fortunately, the RECIPE FOR RECOVERY is perfect for addressing all of those “things” – you know, those thoughts, feelings and behaviors that can distract us from making healthy changes in our lives. That’s precisely why we are presenting the recipe for you to follow! Note: We are deliberately using the verb phrase “to follow” in relation to the Recipe for Recovery because the success of the recipe in creating what it is intended to create requires your ACTION. In this case, the recipe is intended to help you create a healthy life that allows you to live fully at a healthy weight. Just how much “action” is required depends on what you say you want for your life! For example, You decide how much and what type of exercise you’ll do, depending on how physically fit you want to be. You decide how much and what type of food you’ll eat each day to manage the healthy weight you desire. You decide who you associate with and how much time you spend with those people to live as healthy an emotional life as you want to live. You get it! So, we’re clear that AWARENESS is the essential ingredient in the Recipe for Recovery because, well… nothing can be changed if you’re not AWARE that it needs to be changed. If you’re not aware that starches have little nutritional value, then you won’t reduce the number of starches you eat so you can maintain a healthy weight. If you aren’t aware that you have a habit of talking negatively about yourself and/or others, you can’t change it. If someone brings that negative habit to your attention, then you can make a decision about the type of person you want to be and put forth the effort and action needed to make those changes! Awareness IS the first step and the essential ingredient for change. AWARENESS without ACTION, however, is like a treadmill with a bunch of clothes hanging on it – you’re aware that the treadmill is there, but you aren’t using it. We are providing you with the ingredients to include awareness, but it’s up to you to put them into action. We know that being aware of things can be difficult and uncomfortable. This may be the reason so many people focus so much time and energy being aware of things in others rather than focusing on their own problematic behaviors! How often do we know what others must do to change? How much time to do we spend telling others how to fix their problems? We are aware that the neighbors need to mow and water their lawn, but happily ignore our own weeds! Hmm, that might be why one of the main tenets in the 12-Step Recovery world is: Sweep your own side of the street (mind your own business). If you’re more worried about what others are doing wrong, the first step is to become aware of your own “stuff.” To do that, turn those binoculars you’ve pointed at the neighbors directly around and look at yourself. You know, like the “selfie” button on your camera phone…uh, but this time, you don’t have to post your “self-examination” on Facebook! How do you begin to USE the essential ingredient, awareness? Well, if you’ve decided that you want to live fully in Recovery and want to follow the Recipe, we suggest you start by paying attention to your thoughts, feelings, and behaviors – especially when you eat. Start writing down the circumstances surrounding your eating and see if you spot trends. Remember to focus on yourself and what you need to do to live fully. Let others follow the recipe for themselves! Over the course of the next few weeks, we’ll be posting some questions on our Facebook wall to help you identify areas of your life that will benefit from healthy change, so be sure to check in regularly to A Post-Op & A Doc on Facebook. And join us on March 18th for our March APODCast, which will be all about AWARENESS. Be sure to RSVP…it’s totally free (http://www.spreecast.com/events/apodcast-awareness-essential-ingredient)!

A Post-Op & A Doc (Cari De La Cruz and Connie Stapleton, Ph.D.) have officially designated 2015 as the Year of Recovery. There are just six, basic ingredients, which, if added to your life, can help you reach and manage your goals to lose weight and keep it off. The good news is: 1) You already have everything you need to begin following the recipe. 2) It doesn’t involve shellfish, peanuts or milk, so you can’t possibly be allergic to it, 3) There is no baking, cooking, sautéing or mixing required, because the Recipe for Recovery doesn’t involve food, but does involve eating. We like to say that obesity is “all about the food, but it isn’t about the food” (which makes you wonder why we’re talking about a recipe and ingredients). Well, let’s start here: Do you eat when you’re upset, stressed or worried? What are you eating to avoid? Are you eating to avoid a person? a situation? a feeling? By following the Recipe for Recovery, you can learn to deal directly with any upset, stress or worry related to any “what” or “who” so you don’t need to turn to food for a short-term “high” or “fix.” Here’s another one: Do you eat when you’re bored? What do you need when you’re bored? Are you in need of a hobby? Companionship? What are you doing to find a healthy hobby or seek healthy companionship so you don’t automatically turn to food? These are some of the important questions you’ll begin to ask yourself as you learn follow the Recipe for Recovery. We know these are tough things to think about – especially when we’re busy plotting our next snack or obsessing about the box of donuts in the break room at work – fortunately, you don’t need to answer these questions BEFORE you can begin choosing to live in Recovery From Obesity. In other words, you don’t have to know what, where, or why in order to stop the destructive eating behaviors. Basically, food is often a SYMPTOM of a problem – not THE PROBLEM. For example, you might have a problem with interpersonal relationships or issues at work, or perhaps a battle within yourself – like an “emotional storm” -- where you say really mean, negative, unpleasant things TO yourself ABOUT yourself. Rather than addressing the problem, you turn to food, so food becomes the focus rather than the actual problem! Unfortunately, food is a temporary (very temporary) reprieve from unpleasant feelings, memories, or thoughts and though it provides a chemically induced euphoria…it’s short-lived. What is true for the alcoholic is also true for people who abuse themselves with food, which means the problem will still be there when the food is gone…. and then you have the hangover to deal with -- usually in the form of self-brutality by way of horrendously abusive self-talk. Yikes! We created the Recipe for Recovery from Obesity to help you learn to deal with the real issues (stress, worry, boredom, frustration, fear) in healthy ways (and to hopefully avoid the self-destructive eating and subsequent emotional hangovers). Here are the six ingredients that make up the Recipe for Recovery: 1. AWARENESS: Awareness is always the first step in change, which is why we refer to it as the essential ingredient to weight loss and weight-management. It’s pretty hard to change something you’re not aware of. You might know that you’re obese, but are you aware of how you are contributing to the problem? Maybe you’re stuck in your weight loss journey, or you’re regaining, or you never made it to your “goal” – you’re aware that there’s a problem – but you don’t know what to do next. Becoming AWARE of your issues is the place to start. 2. ACCEPTANCE: This is often an overlooked ingredient in weight loss/management. If you don’t accept that weight and the associated issues are ongoing problems in your life, then it’ll be pretty difficult to make the necessary changes to lose that weight and keep it off! The truth is, there are many things we need to accept in our journeys of weight loss/management that you may not have ever considered, such as the fact that you’ll have to eat right and exercise regularly, and will probably have to forego (or greatly limit) some of the foods you really love. The process of acceptance may include having some anger, fear and even mourning. Accept it – and get on with the process! 3. ATTITUDE: We call this the flavorful ingredient (and for some of us, this one is pretty spicy!) We all have different “tastes” when it comes to food… and life, which means that we don’t all like the same things or do the same things in exactly the same ways! Variety is the spice of life? Well, we think attitude is the FLAVOR of recovery! Focusing on attitude and having a positive one can make all the difference in your Recovery results! 4. COMMITMENT: You’ll use this staple ingredient at least once (and sometimes several times) each day in your Recovery journey, especially when you inevitably develop a case of the “I-don’t-wannas” – you know, those moments when you just “don’t wanna…” workout…log your food…manage your portions, pass on the cookies, etc. Adding a dash or a splash of commitment to your life helps you make the next wise choice. Every wise choice moves you toward your desired goals – a healthier self and a better quality of life. 5. ACCOUNTABILITY: Often quite underused, Accountability is an ingredient to help ensure the recipe is prepared as directed. We know it can be tempting to try to do things your own way, and we also know how that’s worked in the past! That’s where accountability really brings the Recipe for Recovery to life! Use accountability to do what you said you’d do when you began your weight loss journey. Whether you chose surgery, medically supervised weight loss, or another structured program, you agreed to do certain things, so this ingredient really matters. Hold yourself accountable for following through with doing the things you said you would do to get the weight off and keep the weight off. 6. EFFORT: The sixth (and key) ingredient in the Recipe for Recovery is Effort. Without ongoing, consistent, “use-it-whether-you-feel-like-it-or-not” – continual effort, the recipe will NOT turn out the way you want. Let us repeat: Your Recovery will NOT be successful if you do NOT use this key ingredient. When you put forth effort, you see results in the direction you are working toward. When you withhold efforts, you also see results – but not the ones you want! And, guess what? You can’t overuse this ingredient, so add it liberally and realize the fullness of a life in Recovery! It may sound like a lot of work, but if you want what you say you want (a healthy life in Recovery From Obesity) -- these ingredients really add up to a winning result!