Hop_Scotch

First off, what is a ketogenic diet?
The ketogenic diet is a very low carbohydrate, very high fat, low-moderate protein diet. Historically, it has been used to control epilepsy in children.
When you don’t give your body carbohydrates (your body’s preferred fuel source), it begins to use and break down body fat as a source of energy, which is called ketosis. The breakdown of fat leads to the production of ketones, and the ketones are what begin to fuel your body (instead of the carbohydrates you were feeding it before). This process can take a few days to achieve, and when done correctly, can be tested by measuring the ketones in your urine with a dipstick. If ketones are present, this means you’re in ketosis.

What does the macronutrient profile look like?
FAT – A ketogenic diet should include healthy fats such as fats from fish, seafood, eggs, nuts, vegetable oils, dairy, and some meats. There is a lot of poor information on the internet that encourages people to have the majority of their fats in the form of cream, lard, bacon, and fried foods, which are not good for our heart.
CARBOHYDRATES – The ketogenic diet is described differently depending on the source, but on average it means limiting your carbohydrates to 5-10% of total daily calories. For bariatric patients eating around 1200, 1500, or 1800 calories/day, this works out to 22, 28, or 34 g of carbohydrates/day, respectively. That’s very little!
Foods rich in carbohydrates that are limited/eliminated in a ketogenic diet include: grain products (e.g. pasta, rice, bread, etc.), fruit, many vegetables (e.g. potatoes, corn, carrots, squash, etc.), some dairy products (e.g. milk, yogurt), legumes (e.g. chickpeas, beans, lentils), and sweets and sweetened beverages (e.g. chocolate, ice cream, pastries, juice, soda, etc.). That’s a lot of food groups being restricted!
PROTEIN – On a ketogenic diet, protein is considered low-moderate (depending on your protein requirement), or around 15-20% of total calories. For bariatric patients eating around 1200, 1500, or 1800 calories/day, this works out to 52, 65, or 78 g of protein/day, respectively. Are these protein targets in the range that your dietitian has recommended for you? For many of you, likely not.
FIBRE – Fibre falls under the umbrella of carbohydrates. Because you now know that carbohydrates are very limited on a ketogenic diet, you can guess that fibre will also be very limited. A diet very low in grain products, fruits, most vegetables, and legumes means that constipation is going to be a real issue!

I heard that a ketogenic diet leads to rapid weight loss.
It’s true in the beginning, but the important factor here is to understand what kind of weight loss this is. Yes, it’s true that reducing carbohydrates leads to weight loss, however the weight that’s initially lost is mainly water weight, not fat.
Here’s a behind the scenes look at what’s going on: Your body always wants to keep your blood sugar well controlled, so it stores some sugar (or glycogen) in your liver. When you’re sleeping, or fasting, your body uses this stored glycogen to send some sugar into your blood, to be sure that your blood sugar doesn’t drop too low. Glycogen is stored in your body by attaching glucose to water. So when we empty our glycogen stores, we’re actually losing a fair bit of water as well, and that’s the initial weight loss that you see. The weight loss that follows from there is partly muscle loss if you’re not meeting your protein needs (which as discussed above, might be the case) and fat.
While ketogenic diets have been shown to be better for weight loss than other low fat diets, the results are only true in the short term. In the long-term, there doesn’t appear to be any difference. You’re also more prone to rebound weight regain on a ketogenic diet once you re-introduce carbohydrates again (whether by choice, by cravings, or by obligation because you feel unwell without them).

But I thought that the ketogenic diet was proven to be effective?
The ketogenic diet isn’t a new diet at all. It’s actually been used for almost 100 years to treat children with severe epilepsy who don’t respond to medication. However, even these children don’t stay on the ketogenic diet their whole lives, they only do so for a temporary amount of time. These children are followed very closely by their doctor and dietitian to very slowly bring carbohydrates back into their diet.

Despite what you dietitians say, I want to try the ketogenic diet!
Ultimately, it’s entirely your decision to try what you want. We (as dietitians) are only here to guide you through the evidence that’s out there, and as of now, there’s no research on the ketogenic diet after bariatric surgery. There’s also not enough long-term research to know and understand if the ketogenic diet is safe for your heart in the long-term (i.e. more than 12 months of being on the diet).
Three of our biggest concerns as dietitians are:
1) Are you meeting your protein needs?
2) Are you emphasizing healthy fats;
3) Are you just looking for a quick fix?
If you’re using the ketogenic diet as a “reset” just like the last fad diet you tried, you’re only feeding the yo-yo dieting pattern (just playing devil’s advocate here!).

Can I be on a ketogenic diet my whole life?
The honest answer is we don’t know. We don’t have research on the long-term effects of following a ketogenic diet. It’s suspected that it may lead to higher cholesterol levels which may lead to heart disease, but more research is needed to conclude this.

Does being on a ketogenic diet guarantee that I’ll keep the weight off?
While more research is needed, one study showed that the participants who were very strict about following the ketogenic diet were able to keep off the initial weight loss for up to 56 weeks (or a little more than one year). We don’t have the research to say if in 10 or 20 years that their weight will still be stable or not. We do know however, that if you don’t find the ketogenic diet realistic for your lifestyle and you end up coming off of it, you will regain the weight (if not more), as with any temporary diet.

Is the ketogenic diet safe?
While it may be generally safe (meaning you’re not going to die) for most people, you should always check with your doctor, especially if you have heart disease, liver disease, and diabetes, as this diet may put your health at risk.
The ketogenic diet is not considered safe for those who have chronic kidney disease.
The ketogenic diet has received a lot of criticism because it’s a very restrictive diet, eliminating many foods and therefore many nutrients that are important for health. Following this diet puts you at high risk for micronutrient deficiencies. Make sure you discuss additional vitamin supplementation with your family doctor or dietitian.

What are the benefits of a ketogenic diet?
Aside from weight loss, following a ketogenic diet has been shown to improve blood sugar control in those with type 2 diabetes, lower triglycerides, lower LDL cholesterol (the ‘bad’ cholesterol), and raise HDL cholesterol (the ‘good’ cholesterol). Although these benefits sound attractive, know that other low fat diets have produced similar results, and would be safer in the long-term since they’ve been better studied and are less restrictive overall.

What are the risks of following a ketogenic diet?
Liver disease? – More research is needed, but several rat studies have shown an increased risk of developing liver disease. While results from rat studies don’t 100% translate into humans, animal studies often give an indication or at least a starting point for how something will affect the human body. More research is needed in human subjects. Muscle loss. – Another risk of following a ketogenic diet is muscle loss, because most patients aren’t able to meet their protein goals. Losing muscle may put you at risk of weight gain. Working with a dietitian while following a ketogenic diet can help you be sure you’re meeting your protein needs. Earlier death? – Like we’ve mentioned, there isn’t enough research yet on the long-term risks of following a ketogenic diet, but a recent study found that low carbohydrate diets (less than 40% of calories from carbohydrates) was linked to earlier death, compared to having a moderate-carbohydrate diet (50-55% of calories from carbohydrates). Remember that a ketogenic diet has around 5-10% of calories coming from carbohydrates. How did they explain this increased risk? The risk with a low carbohydrate diet seems to be because the carbohydrate calories are often replaced with more animal protein and unhealthy fats, rather than plant-based protein and healthy fats. Note that this study was not on bariatric patients, but again, the findings are interesting.

What are the side effects of a ketogenic diet?
Side effects during the adaptation period (i.e. in the beginning of following a ketogenic diet) include:
brain fog, fatigue, headaches, nausea, strong smelling sweat and urine, constipation or diarrhea, and poorer exercise performance. Long-term side effects include:
bad breath, micronutrient deficiencies, and muscle loss.
What are common misconceptions of the ketogenic diet?
Many people believe that it’s a carbohydrate-free diet, meaning no carbohydrates at all. This isn’t the case. You can have in the range of 20-50 g of carbohydrates per day (depending on how many calories you’re eating). If you don’t know what this looks like in terms of food, speak with your dietitian.
Another misconception is that a ketogenic diet is high in protein. This also isn’t the case. A ketogenic diet is moderate in protein for the average person (who hasn’t had bariatric surgery), and is therefore typically low in protein for a bariatric patient. As you likely know, low protein puts you at risk of losing muscle which will affect your overall weight loss, and put you at higher risk of weight regain in the future.

Other than muscle loss, what are other negative nutrition consequences of following a ketogenic diet after bariatric surgery?
Low in fibre – The smaller food intake that you have after surgery already makes getting in enough fibre difficult. This partly explains why so many people are constipated after surgery. A ketogenic diet significantly limits most fibre-containing foods including fruit, most vegetables, grain products, and legumes, so your fibre intake decreases even more. Constipation is therefore even more of an issue! High in unhealthy fats – Many people don’t follow a ketogenic diet correctly and include too much saturated fats (or unhealthy fats) in their diet. For example, they may choose bacon, sausages, and lard, over fish, nuts, and vegetable oils. A diet high in saturated fats has been linked to heart disease. Low in many micronutrients – A ketogenic diet is also low in important vitamins and minerals such as thiamine, folate, vitamin A, calcium, magnesium, iron, and potassium. While you’re prescribed vitamins and minerals supplements after bariatric surgery, these standard prescriptions don’t account for you following a ketogenic diet. If you do decide to follow a ketogenic diet, it’s important to have your doctor or dietitian re-assess your vitamin and mineral supplements and for you to continue doing blood work regularly.
Will I be able to exercise just as much while on a ketogenic diet?
The downside to following a ketogenic diet is that it may actually reduce your exercise performance (across anaerobic, aerobic, and strength related exercises) in the short-term. If you’re doing low intensity exercises such as walking or a leisure bike ride however, you shouldn’t notice a difference. More research is needed to understand how a ketogenic diet affects exercise performance, especially in the long-term.

I’ve been having episodes of low blood sugar after bariatric surgery. Can I follow the ketogenic diet?
If you’ve been experiencing low blood sugar after surgery, it’s not recommended to start a ketogenic diet. It’s important to understand why you are experiencing low blood sugar as soon as possible.
Here are some of the most common reasons for low blood sugar after bariatric surgery:
Dumping syndrome due to high sugar intake Going long periods of time without eating Not eating enough carbohydrates or not spacing your carbohydrates out during the day Excess exercise An overactive pancreas Diabetic medication that is not adjusted properly Speak with your dietitian to figure out why your blood sugar keeps dropping.

I plan to try the ketogenic diet for a few weeks and then come off of it.
If that’s the case, then don’t bother. The reason this diet works for weight loss is because you are in ketosis (which in itself takes a couple of days to achieve because you need to use up your glycogen stores). If you come out of ketosis, you will no longer see the effects, and thus begins the yo-yo dieting effect.
Always remember – Temporary changes yield temporary results!

I’m already on the ketogenic diet, how can I come off of it safely?
If you’ve already started the diet, reintroducing carbohydrates can lead to bloating, unstable blood sugars, and weight regain. To minimize these effects, begin by including whole grain products, rather than refined processed carbohydrates (e.g. white bread, breakfast cereals, pretzels, etc.). Whole grain foods include quinoa, brown or wild rice, oatmeal, bulgur, and barley. Sweet potatoes would also be appropriate. Include 1 to 2 tablespoons at only one meal per day for up to one week. If you’re feeling okay, begin including one fruit at one snack for a few days, and then try reintroducing yogurt and milk.

But aren’t there doctors and health gurus out there promoting the ketogenic diet?
Yes, there are, but there also were doctors and health gurus promoting the Atkins diet, the Pritikin diet, and the Dukan diet back in the day. There will always be people out there trying to capitalize on the newest fad diet to sell you on the weight loss dream and to take your money. It’s easy to point fingers and put the blame on specific foods or food groups, but ultimately the only way of eating that has been proven effective time and time again, is moderation. As dietitians, we know very well that ‘moderation’ (which means something different for each of our clients) isn’t sexy, but it’s key to having a healthy long-term relationship with food.

I’m pregnant and I want to follow a ketogenic diet.
Following a ketogenic diet during pregnancy is not recommended. While your body can handle being in ketosis, the production of ketones is harmful to your baby’s development, particularly their brain development.

SUMMARY…
– A ketogenic diet is very low carbohydrate, very high fat, low-moderate protein diet.
– A ketogenic diet should emphasize healthy fats, but many sources online emphasize online unhealthy fats (e.g. bacon, sausage, lard, cream, etc.).
– A ketogenic diet is very low in carbohydrates. This means that it’s not only grain products that are limited (e.g. pasta, rice, bread, etc.), but also fruit, many vegetables, some dairy products, legumes, and sweets.
– By default, a ketogenic diet is also low in fibre which results in constipation in many patients.
– A ketogenic diet is considered low-moderate in protein. Most bariatric patients aren’t able to meet their protein needs on ketogenic diet which results in muscle loss.
– We don’t know the effects of a very high fat diet on health long-term, but it likely isn’t good for heart health.
– Many of the benefits of a ketogenic diet (e.g. weight loss, improved blood sugars, lower triglycerides, lower LDL cholesterol, increased HDL cholesterol, etc.), are similarly seen in low-fat diets (while being way less restrictive overall).
– There are many unpleasant side effects to following a ketogenic diet including constipation, poorer exercise performance (at least short-term, no research on long-term performance), muscle loss, bad breath, and micronutrient deficiencies.
– You likely need to take additional vitamin and mineral supplements while following a ketogenic diet. Regular blood tests are still very important.
– A ketogenic diet is not recommended in a variety of health conditions, and is even considered dangerous for some (e.g. patients with chronic kidney disease and pregnant women). Always check with your family doctor and dietitian before making drastic changes to your diet.
– The ketogenic diet has not been studied in people who have had bariatric surgery, so the short-term and long-term effects are unknown.
– The ketogenic diet is very restrictive and is therefore not sustainable for the majority of people. Eating out and socializing around food become almost impossible.

Our final thoughts…
Many patients are quick to blame carbohydrates for weight regain. Instead of jumping to a ketogenic diet, we recommend reviewing the bariatric basics and booking an appointment with your bariatric dietitian.
If you absolutely insist on trying a ketogenic diet, we suggest a “modified keto diet” that consists of more plant-based protein and healthy fats, with enough protein to be sure you’re maintaining your muscle mass.
What are your thoughts on the ketogenic diet? Have you been tempted? Are you currently following a ketogenic diet?
– Lisa & Monica, your bariatric dietitians

P.S. For more tips on healthy living after bariatric surgery, follow us on Facebook (@bariatricsurgerynutrition) or check out our highly praised book HERE!

“Complete” But Lacking Essential Nutrients
What does a “complete” multivitamin contain? It could provide anything from all the essential nutrients to just a few. There is no legal definition for “complete.” In the case of Flintstones “Complete” multivitamin chewables, “complete” apparently means that it has all 13 vitamins, but only 6 of the more than 15 essential minerals that you need.
Quantity Is Critical
For bariatric surgery patients, it is not only important to get each of the necessary vitamins and minerals, but also to have the right amounts. You need high amounts of some of the vitamins and minerals, and Flintstones chewables simply do not deliver. For example, the American Society for Metabolic and Bariatric Surgery (ASMBS) suggests at least 12 mg thiamin (vitamin B1) per day, while a chewable has 1.5 mg.
You will also be short on:
Vitamin A Vitamin D Vitamin E Vitamin B12 Iron Calcium And more.
“Doubling Up” Does Not Work
If one tablet is not enough, can’t you just take two? Well, not really. First, getting twice as much as certain nutrients may still leave you short. For example, 2 Flintstones chewables provide 1,200 IU of vitamin D, while recommendations for post-op gastric bypass patients are to get 3,000 IU per day. And no matter how many chewables you take, you will never get enough of essential minerals such as selenium and chromium, since the chewables have none.
Multivitamin: What Is in a Name?
We usually refer to them as “multivitamins,” but most often, we really mean, “multivitamin and mineral supplements.” Sometimes, a “multivitamin” that you buy off the shelf really is literally a bunch of vitamins with few or no minerals. Do not get confused by the name when purchasing your supplement. Read the supplement facts label to see which nutrients are in the supplement, and how much there is.
Safe Choices, Your Way
To be sure that you are getting the right supplement for bariatric surgery post-op needs, you are best off choosing a bariatric supplement. It may be a tad more expensive, but it could prevent deficiency diseases such as anemia or peripheral neuropathy. The BariatricPal Store has Multivitamin One and a wide range of other multivitamin and minerals formulated according to ASMBS guidelines.
Choosing a bariatric surgery-targeted multivitamin instead of a kids’ supplement does not mean you have to choke down capsules if you cannot stand them. You can always opt for another form, such as Powder or a Soft Chew. BariatricPal Protein One has 28 essential vitamins and minerals, along with protein and fiber, in Unflavored powder or great-tasting shakes such as Chocolate, Vanilla, Cookies and Cream, Peanut Butter, Chicken Soup, and more.
For help figuring out which vitamin and mineral supplement may be right for you, you can look at the attached ASMBS guidelines or check out our Bariatric Vitamin Guide, which breaks down recommendations for each surgery type. Also, be sure to talk to your doctor about your individual needs before trying a supplement.
ASMBS-Nutritional-Guidelines-2016-Update.pdf

Try to see their side.
You are asking them to see it from your perspective, so it is only fair that you try to see it from theirs. What are the reasons they may be against your Weight Loss Surgery, and how can you address them? In many cases, their concerns are legitimately about your well-being, and things you should consider if you have not already. They may worry that:
You will not hit your goal weight this time since they’ve seen disappointment before. You will suffer complications from surgery. You will regret having a permanent Sometimes, their concerns are selfish but still worth discussing. They may worry that:
You’ll stop feeling attracted to them. You will pressure them to give up their own favorite foods while you eat healthily. They will feel left out. You will not want to spend time with them. Reassure them.
Address their concerns directly. Explain why you feel the surgery is safe, and how much research you have done to learn about it as well as find a surgeon. Tell them why you think Weight Loss Surgery will work for you even if previous diets have not.
Let them know that you need to do this for yourself, not for them and that this will not change the way you feel about them – you will still love your SO, and respect your parents, for example. Tell them how you see yourself spending time with them after surgery, so they can be comfortable.
Write it down and practice.
Starting the conversation can be the scariest part of telling them. Before you bring up the subject, write down what you plan to say. This is a good exercise for you to do anyway since it encourages you to think through all of the doubts around Weight Loss Surgery. Writing it down and practicing can make it easier for the words to come when you decide to bring it up.
Include them in your plans.
Often, your spouse and parents, and others who care about you, just want to help. They may be afraid if they do not how to help. When you talk to them, let them know how important they are to you, both in life in general and in this important period of your life. If you tell them specifically what they can do to support you, they may feel more at ease with your decision and more confident in their roles.
You might ask them to:
Pick up your children from school when you are recovering from surgery. Go with you to the store to pick out protein powders and measuring cups and spoons. Ask you each night how you are doing. Cook healthy meals with you. Prepare for anything.
The conversation may be as difficult and unfulfilling as you feared. Or, your SO, parents or other loved ones may be surprisingly supportive once they realize that you have done your research and are serious about making the lifestyle changes needed for success. They may even be interested in getting healthy with you and ask for your help and support in exchange for theirs.
Stay strong and independent.
As much as you long for your SO and other loved ones to support you wholeheartedly, it may not happen. Try not to let it get you down, though. If you are sure about what you want, go for it, with or without them. They will come around sooner or later, and if not, you may be better off without their negative influence. Letting them know that you have made up your mind regardless of their support may actually convince them to help you since there is no point in standing in your way.
Stay independent in the sense that you realize that you do not need them. Your success does not depend on their approval, and you are not doomed to fail if they stand in your way. Get the support you need from others as you move forward.

Consider this: you can be 10 times more likely to achieve your goals if you make New Year’s resolutions than if you do not. That statistic may motivate you to take a little care in setting your goals for this year. So, here are a few tips for setting resolutions that you can keep.
Make Them Realistic
We all want to hit goal weight and stay there, but is that realistic for you? Probably not, if you are more than 70 to 100 lbs. overweight and have not yet had weight loss surgery. A more realistic resolution might be to schedule your surgery and then lose an average of 5 to 10 lbs. per month after surgery.
These are some additional examples of unrealistic and realistic resolutions.
Get to the gym every day. Work out at the gym or walk 5 days per week. Follow your diet perfectly. Get back on track within a day of losing control. Avoid all restaurants. Check the nutrition facts beforehand and make healthy choices when you order. Plan all meals and snacks ahead of time. Keep protein bars and other healthy protein snacks on hand for when you need them unexpectedly. Make Them Specific Yes, you want to lose weight for example. But how much do you want to lose? Your resolution might include the number of pounds you want to lose or the BMI you want to hit. It might be to lose back the pounds you regained after weight loss surgery a few years ago. Here are some other examples of specific resolutions to consider.
Drink at least 64 ounces of water per day. Attend two support group meetings each month. Eat at least two servings of fish per week. Eat at least 65 grams of protein per day. When you make your goals specific, you know whether or not you are making progress towards them and when you hit them. That is motivating, and it keeps you honest with yourself.
Consider the Process
A goal is an endpoint. Your resolution might be to achieve those goals, but it should also include the process, or “how” you are planning to get there. If your resolution is to eat five servings of fruits and vegetables per day, your process might include storing canned and frozen vegetables so they are always available, keeping washed and cut fruits and vegetables in the fridge for snacks, and adding a half-cup of vegetables to your omelets.
Here are some more examples of ways you can focus on the process.
To hit your pre-op weight loss requirements, swap water for soda and side salads for fries. To get to the gym more often, lay out your clothes and shoes the night before, and figure out which workout you will do once you are at the gym. To move closer to your weight loss surgery, find out how to get approval for insurance reimbursement (or how you will finance your surgery) and which surgeons are your top choices. To get your blood sugar levels down, healthify your carb choices by identifying which are sugary and refined, and swapping them with high-fiber, unrefined whole grains, beans, and fruits. Stay Accountable
Your resolutions are important to you, so make them a priority and hold yourself accountable. One way is to use the buddy system. You can either find a buddy with resolutions similar to yours, or just use a buddy who is willing to hold you accountable. Check in regularly with each other on your progress, encourage each other, and ask the tough questions if either of you are falling off track.
Another way to hold yourself accountable is to use a log. Use an old-fashioned pencil and paper log, or opt for an online or smartphone app. Depending on your resolution, you can record thoughts, feelings, and progress, as well as food intake, weight, and exercise. Seeing your efforts in black and white can keep you honest and motivate you to keep going.
Be Patient with Yourself
Recognize that you won’t do it all at once, and that you will make mistakes. Set smaller incremental goals so that you can see progress in January, but keep the big picture in mind and realize that your resolutions are long-term. The big payoffs will come later in the year if you stick with your resolutions.
Also, have a plan to forgive yourself, because things will go wrong. Dust yourself off and get back up, because you can achieve your goals!

First off, I just want to say this very important thing, if you take nothing else away from this article, let it be this- People’s reactions to you are based on their relationship with themselves, not you. Always.
Someone who is living at peace with themselves will have no need to harshly criticize, no desire to humiliate, and no feelings of unresolved jealousy. Sadly, once you understand this, you also realize how many people in your life are unhappy with themselves on some level. It makes it a little easier not to take things personally, but I would be lying if I said those things don’t hurt anymore.
So how do you deal with friends and family members who are not living at peace with themselves? What practical steps can you take to be at peace with yourself so that you are able to reject those statements and hurtful judgments instead of internalizing them?
Here’s the bottom line- You will always have people in your life who do not wish you well, who want to see you fail. If you do not learn to look past them and stay focused on you and your progress, and live at peace with yourself- you will experience re-gain. I love the words from Eleanor Roosevelt, “No one can make you feel inferior without your consent.”
1) Start with yourself- You need to be at peace with yourself. Who you are, what you weigh, your progress level, etc. Easier said than done, I know. But working towards that will allow you to bypass other’s opinions of you because you know who you are and where you’re going. A simple way to begin embracing yourself is positive self-talk. Start by looking into the mirror as often as you can, and saying things to yourself like, “I am a beautiful, peacefully person and I love me.” Say hello to yourself. “Hi Ash, you are a wonderful, beautiful person and I am SO proud of you.” It’s going to feel super painful and may trigger some emotions. Process those as they come, don’t shy away from the feelings that embracing yourself brings. If you need to cry, do so. If you smile, embrace it. Enjoy yourself. Changing that negative narrative in your head that so many of us carry around, is step one.

2) Be honest- When someone says something that’s offensive, it usually comes from one of 2 places: a poor relationship with themselves, or a lack of education. Use your best judgment to determine which it is. Keep in mind, there are a LOT of myths and misinformation surrounding bariatric surgery. Don’t assume people know more than they do. Think back to before you became an expert on Bariatric Surgery. How many questions you had, how many myths you thought were accurate. Seek to educate. But be honest, if someone makes a hurtful comment, let them know. Keep it simple, “Hey, that was uncalled for.” or “Please don’t say things like that to me.” Try to stay calm and in control.
3) Take a break- If you need a break, take one! Go for a walk, get out of the house, go listen to music alone. Don’t feel bad for needing a break. Family time can be stressful, don’t allow others to jeopardize your progress. When you’re stressed and anxious, you’re more prone to overeating which puts you back on that harmful cycle you’re working so hard to stay off of. Give yourself permission to stay home sometimes too, you don’t need to be at every single family gathering. It’s okay to opt out. People may get offended, they may try to make you feel guilty, but remember- it’s not about you. It’s all about how they feel about themselves. Those who are at peace with themselves will support you and do their best to understand where you’re coming from.
4) Stay focused- This is a tough one. Holidays pull our focus in so many directions, it’s easy for us to lose focus on our goals. Be proactive about making plans for yourself for food and exercising during the holidays. Being ahead of the game and staying on top of your plans will make you feel peaceful and accomplished. When you feel this way, your confidence is harder to shake and you will feel more secure. When you’re focused on a goal, it consumes your focus and the other things that pop up to derail you just fade into the background. Stick to your routine, take your supplements, and stay on track. You can do this!
5) Stay connected- Join a support group in-person or online, find an accountability buddy, hire a coach, or grab a friend who will keep you focused without judgment. Someone you can call, text or write to keep them updated so they can provide you with the encouragement you may not be getting from others this season. Having connection fills an emotional need that many try to fill with food. If you’re getting that need met, you won’t be as tempted to eat for comfort. Connection is something we all need, so make it a priority to have someone in your corner this holiday season.
Remember, at the end of the day- this season is temporary. All the food, all the family, all the hustle and bustle. The things that can make or break this season. It’s all temporary. You are what you carry into the New Year. Your health journey is what lasts. Keep your sights on the long term. You can do this, I believe in you!

Regardless of how marijuana is taken (i.e. smoked, inhaled or eaten) the effects are the same. The majority of people who use marijuana describe a sensation of relaxation and euphoria (the “high”). Some people however react badly to the drug which can result in a state of panic, anxiousness and fear, or in some cases even hallucinations if they take too much.
Of particular relevance to bariatric or weight loss surgery, is the fact that marijuana impacts the part of your brain that controls appetite. Have you heard of the “munchies”? Yep, that’s right, the “munchies” are a real thing! Marijuana can increase your appetite, causing you to eat more, which obviously is not great if your goal is weight loss.
Interestingly, a recent study on weight and marijuana use actually showed that marijuana use may very slightly (and we mean VERY slightly) reduce body weight (about a 0.5% reduction in BMI) (1). This study however was conducted on a group of people with an average BMI of 27 kg/m2, which is way below the average bariatric or weight loss surgery patients’ BMI pre-surgery. This unfortunately means that this mild weight loss effect cannot be applied to the typical bariatric or weight loss surgery patient.
We did however find one recent study done in 2016 that is more relevant to the bariatric or weight loss surgery population (2). The study was run on a group of 50 patients (62% being RYGB patients) all 2 years after surgery. The results of the study showed that the patients who had smoked marijuana within the last 30 days and the patients who had started smoking more since surgery, were all more likely to have disordered eating habits, specifically “loss of controlled food intake” (2). Although the study did not look at weight outcomes related to marijuana use, we know that disordered eating habits such as grazing and bingeing are risk factors for weight regain after bariatric or weight loss surgery.
In conclusion, we do not yet fully understand the effects of marijuana use after surgery with respect to weight loss and longer term weight maintenance outcomes. The field of research is still very young (3). Regular marijuana use however may pose medical risks after surgery, therefore speak with your surgeon if you have been prescribed marijuana for medical reasons. Furthermore, if you choose to use marijuana for recreational reasons on a regular basis, it is worth discussing this habit with your bariatric nurse and dietitian.
– Monica & Lisa
*******
Join our monthly newsletter to receive access to all our blogs and exclusive dietitian-approved tips to optimizing your weight loss and maintaining your weigh long-term!

http://eepurl.com/c-qfcL
*******
References:
1. http://onlinelibrary.wiley.com/doi/10.1002/hec.3267/full
2. http://www.sciencedirect.com/science/article/pii/S1550728915002063
3. https://www.ncbi.nlm.nih.gov/pubmed/24913244

There are many options when it comes to paying for bariatric surgery. Let's explore them. Click on each hyperlink to learn more on the topic.
Having health insurance does not mean that weight-loss surgery is covered in your policy. About one quarter of people seeking weight-loss surgery will be denied three times before they receive weight-loss surgery insurance approval.
If you have insurance coverage for bariatric surgery and are denied, you have the right to contest the decision and write a bariatric surgery insurance appeal letter.
Since many health insurance plans exclude weight loss surgery, this leaves people faced with the decision to self-pay for bariatric surgery or to forgo what could very well be a life-saving procedure given the devastating effects of obesity and obesity-related diseases on health.
An option is to take out a medical loan for weight-loss surgery.
However, bariatric surgery is expensive if health insurance will not cover the surgery. And many people seek bariatric surgery outside the U.S. and engage in the process of weight loss surgery medical tourism.
Thousands of individuals head to Mexico for Bariatric Surgery to realize excellent quality care, fast wait times, and attractive prices.
With the question of safety of weight loss surgery in Mexico being being top of mind, I turned to Alex Brecher founder of BariatricPal Hospital MX for further exploration. Alex Brecher opened the BariatricPal Hospital MX in 2017 after having run a Mexico medical tourism business for 10 years.
As far as free bariatric surgery in the US, while it will no doubt be a challenge, free weight-loss surgery is within the realm of possibility. Free or reduced cost WLS grants and charity care are available.
There also are bariatric surgery clinical trials for surgical weight-loss candidates. Use our Match to Clinical Trials in 60-seconds widget on the bottom right column of MyBariatricLife.org to locate a trial near you.

There are two main reasons bariatric patients are at risk for developing vitamin and mineral deficiencies:
1. First of all, and most obviously, you’re no longer able to consume large enough amounts of foods to meet your micronutrient (i.e. vitamin and mineral) needs.
2. Secondly, your body now absorbs and processes foods differently. For example, if you had a malabsorptive weight loss surgery (e.g. gastric bypass or duodenal switch), in addition to eating smaller portions of foods, you’re also not absorbing 100% of the nutrients in the foods that you’re eating.
Interestingly, even in the non-malabsorptive procedures (e.g. sleeve gastrectomy and band) we see changes in nutrient processing. For example, you may no longer have enough stomach acid in your small stomach to efficiently absorb the natural calcium found in dairy products, which is why you’ve been prescribed a special type of calcium, calcium citrate, that doesn’t require stomach acid to be absorbed.
The signs and symptoms of vitamin and mineral deficiencies can be mild to severe.
Some take only weeks to occur, while others take years to develop. While many deficiencies are reversible (e.g. anemia, or low iron), several micronutrient deficiencies are irreversible (e.g. osteoporosis, or bone decay due to inadequate calcium and vitamin D, and neurological damage due to inadequate B vitamins).
Moral of the story? Take your vitamins!
How often should I be going for blood tests?
Your bariatric team will tell you how often you should have blood tests done. It’s most likely that you’ll have a blood test after your surgery, while you’re still in the hospital. Following this, your next blood test will be in three to six months and continue every three to six months until your first year after surgery, depending on the type of surgery you had. If your blood tests are looking great at one year after surgery, this is a good sign and means that you managed to get through the first risky year after bariatric surgery without having developed a deficiency!
But this doesn’t mean that blood tests are no longer needed. You’ll need to do blood tests to check for nutrient deficiencies for the rest of your life. As you get older, your body needs more of some nutrients and less of others as your body changes. Some deficiencies also take a longer time to develop. For this reason, you may still develop deficiencies over time, even five to ten years after surgery. We’ve seen many patients who stopped doing their blood tests because they felt fine only to find out years later that they have multiple severe deficiencies. Feeling good doesn’t mean everything is good. And there’s a reason why.
Before feeling tired, lethargic, weak, or sick, because of a nutrient deficiency, your body goes through the following stages:
You’re not getting enough of a nutrient from your diet and your vitamins; Your body doesn’t have enough of the nutrient stored; You begin to have low levels of the nutrient in your body; Your organs begin to have trouble working properly; You begin feeling unwell and develop symptoms of deficiencies. Feeling unwell is the last step in this process.
These steps can take only a few weeks for some nutrients, and up to several months for others. When you begin to feel unwell, your body has already been through weeks—or months—of missing an important nutrient. Blood tests can catch these deficiencies at a much earlier stage.
For example, say you stopped taking your iron pill. You wouldn’t feel an anemia, or an iron deficiency, developing. Gradually, over time, you’ll begin to get tired and you might figure it’s just your busy lifestyle. You’ll begin to feel worse and wonder if you’re just not getting enough sleep. Then you’ll become increasingly lethargic and notice your hair has lost its shine and is getting brittle. Lastly, you’ll notice that you can hardly get through your morning routine without having to sit down and take a break. You’ll go to your doctor who will order blood tests. The blood tests will come back diagnosing you with anemia. Luckily, you’ll restart your iron supplement which will reverse this condition, although it’ll take about three months until you feel like yourself again. However, some deficiencies aren’t reversible which can leave you unwell permanently.
The bottom line:
Have your blood tests done regularly as suggested by your bariatric team. You’ll eventually only have one blood test per year, but this will only be the case at two years after bariatric surgery or until your blood tests routinely come back normal. If you no longer see your bariatric team, or live too far from your bariatric center, make sure that your family doctor is testing you for bariatric surgery-related deficiencies. The routine blood tests that your family doctor performs aren’t the same ones that your bariatric team orders. We look at so much more. Ask your family doctor if he/she is looking for all the nutrients necessary for bariatric surgery. They can receive this information from the bariatric clinic where you had your surgery.

Why Weigh Yourself?
Yes, you weigh yourself to know how much you weigh. But what is the point if you are on your weight program and your doctor will weigh you at your next appointment? Weighing yourself can have some benefits.
It can help you lose more weight by keeping you accountable. Just like logging your food can make you think twice before taking that extra bite, knowing that you will face the scale can keep you from serving yourself another portion.
It can be motivating. When you see the number of the scale go down, you might be more eager to wake up early for your workout, or order a salad instead of a sandwich.
It can be empowering. Knowing your weight gives you another piece of information about your body, and embracing rather than avoiding yourself can empower you to do your best for yourself.
How Often?
You can weigh yourself as often as you like, but it does not make sense to take too many weigh-ins too seriously. For many people, a good rule of thumb is to do a weekly weigh-in. You can take this weight as your “official current weight.” Some people like to stay off of the scale between their weekly “official” weigh-ins, while others like to weigh themselves daily, or even more than once a day, just to see what is going on. That is fine, as long as you do not take each weigh-in too seriously and do not let it bother you.
How to Weigh Yourself
You may be a 10, 20, or 40-year veteran of weighing yourself, but there are better and, well, worse ways to do so. It may be worth reviewing or revising your weigh-in practices to get better results. Here are some guidelines for accurate weigh-ins.
Weigh yourself at the same time of the day for your weigh-in, usually first thing in the morning.
Choose the same day each week to weigh yourself.
Wear minimal or no clothing.
Use the same scale, and a trustworthy one, each time.
Mistakes to Avoid
In theory, weighing yourself is as simple as stepping on the scale. Not! Your weight can be deceptively high or low if you find yourself making any of these mistakes.
Weighing yourself after a heavy meal. While 1 lb. of lettuce has only 50 calories, it weighs…1 lb. If it is in your stomach, you will weigh an extra pound. Weighing yourself in the morning before you eat anything can help avoid the problem of extra weight inside your stomach.
Weighing yourself wearing shoes or clothes. Heavy shoes and a full set of clothes can weigh 5 or more lb. That is a big chunk of weight that is not yours!
Weighing yourself with too much salt in your system. With salty foods comes sodium, with sodium comes thirst, and with thirst comes extra water. Water is heavy. It can still be in your system the next morning, and show up on the scale.
Weighing yourself right after exercising. Exercise does help you lose body fat, but it also helps you lose body water through sweat. You can lose a few lb. of water in one workout, and your body weight might be artificially low right after.
Weighing in Monday morning. If your weekdays are picture-perfect in terms of eating, and your weekends progress from Friday night at the bar to Sunday afternoon in front of the TV, your Monday morning weight can be variable, and possibly high. Friday morning may be a better time for you to weigh in.
Getting inaccurate numbers can be bad in many ways.
You might get discouraged for no reason if your weight shows up as higher than it really is.
You could become confused about how what you eat affects your weight if there seems to be no correlation.
You might have trouble detecting regain, and not modify your diet until you have gained more than you wanted.
Choosing a Scale
On top of making sure you are ready for a good weigh-in, you need to make sure that your scale is also ready. Using a cheap scale can drive you crazy because it may not be accurate. It could be difficult to read, or it could vary within a few pounds even if you are the same weight.
There are many affordable Body Scales that are highly accurate. You can find features that help you read the scale easily, track your weight, and see other information. These are some features to consider.
Digital read-outs.
Bluetooth connectivity to your smartphone.
Memory of your recent weights.
Measurements such as body fat and lean muscle mass.
Use the scale to help you on your weight loss journey, and you can consider it another weapon in your weight loss arsenal. The more tools you have, the better your weight loss success can be!

Drinking water after surgery can cause some discomfort (like a rock hitting your stomach), sometimes it doesn’t taste right because of taste changes after surgery, and sometimes the temperature of the water can leave you feeling uncomfortable. Other times, you may simply just forget to drink and you just don’t feel as thirsty.
Not drinking enough water can leave you dehydrated.
How do you know if you’re beginning to get dehydrated? There are 3 main ways of figuring this out:
Do I pee 3 times per day, or less? Is my pee dark yellow in colour and smells more than usual? Do I get dizzy when I stand/sit up or bend over? If you’ve had bariatric surgery and answered yes to one or more of these questions, there’s a chance you may be dehydrated. Some of these symptoms can be related to other causes as well, so check with your doctor, bariatric dietitian, or nurse if you’re unsure.
Here are our tips for drinking more water after surgery:
Make water more convenient by…
Buying a fun new water bottle for work and home that gets you excited. Ideally, something colourful that catches your eye; Keeping a water bottle or water glass within arm’s reach at all times, regardless of where you are (e.g. at work, in the car, on the couch, in bed, etc.); Keeping cold water in the fridge at all times. Buy a water pitcher or a water filtering jug and place it at the front of your fridge. It needs to be visible and easy to reach to be convenient; Knowing your environment. Do a tour of your workplace to remind yourself of where the water fountains or coolers are. Check if the cafeteria charges for hot water or if there’s a vending machine that sells water bottles close by; Buy a smaller water bottle to carry in your purse or backpack for when you’re on the go. Ideally, it should hold no more than one to two cups. Large water bottles are often intimidating and if they are too heavy or bulky, they’re more likely to get left behind; Leave a reusable water bottle in your car at all times so that you always have some on-hand.
Get excited and add some flavour by…
Trying infused water. Add one of the following combinations to your water pitcher or water bottle:
Sliced cucumber + fresh mint leaves; Sliced strawberries + fresh basil leaves; Sliced lemon + fresh lavender; Blackberries + fresh thyme; One cinnamon stick (for best results leave overnight in your water bottle); Using flavoured ice cubes.
This idea involves freezing concentrated fruit purees, spirals of citrus rinds, and/or fresh herbs into ice cube trays. Adding one to three of these ice cubes into your water not only adds a fun flavour and keeps your water colder, but it’s also a colourful touch. This is a great alternative to store-bought water enhancers that contain artificial sweeteners.
Example: puree two cups of chopped watermelon with the juice of one lime. Freeze the mixture in ice cube trays. Add two ice cubes into your reusable water bottle; Making a homemade tea with an added twist. Add eight ounces (one cup) of boiling water to the combinations below. Drink hot or refrigerate overnight and enjoy cold.
1/2 sliced lemon + 1/2 inch piece of peeled fresh ginger + 1 tsp honey; A green tea bag + fresh mint leaves; A black tea bag + orange slices or peach slices; An earl grey tea bag + sprig of lavender + lemon slices +1 tsp honey; A white tea bag + mint leaves + dash of lime juice; Treating yourself to some loose tea leaves or flavoured tea bags at specialty shops. Set reminders by…
1. Downloading an app. There are countless free apps out there to help you track your daily water intake and even ones that will send you constant reminders throughout the day to drink;
2. Add a sticky note to your computer monitor. Be sure to change the placement of the sticky note every week so it doesn’t blend into the background;
3. If you’re someone who does repetitive tasks at work, use this to your advantage! For example, challenge yourself to take three sips of water every time you read a new email and every time you send an email;
4. Buy a ‘time stamped’ water bottle or simply recreate one by writing the hours of your work day down the side of your bottle with a permanent marker. For example, evenly space 9 a.m., 10 a.m., 11 a.m., and 12 a.m. down one side of the bottle and 1 p.m., 2 p.m., 3 p.m., and 4 p.m. down the opposite side of the bottle. This strategy will also help you to pace yourself throughout the day.

– Lisa & Monica, your bariatric surgery dietitians

The Key Points:
The main key is the power of the motor. The more powerful the motor, the faster the blades rotate. A motor that is 900 watts will mix much better than a motor that is 300 watts. An evenly smooth texture is more likely with more powerful blenders and mixers. The products listed are ones our patients use more frequently. Look for a blender that is in your budget, works well for what you want to use it for and how easy it is to clean. Keep in mind how much space you have in your kitchen, too. Some of the blenders/mixers can only pulse and may list a time limit on how long to pulse. Products listed are for making protein shakes or smoothies only. Shaker Cups
Widely available in many retail stores and in the BariatricPal Store. Prices range from $6-$20. Made to mix protein powders with fluids. Easy to carry with you. Great for traveling. Sometimes it’s more difficult to mix the protein powder completely in a shaker cup. PROMiXX (original) and version 2.0 Vortex Mixer Original lists for about $30 on Amazon. Needs regular batteries. The 2.0 has a rechargeable, lithium battery that requires a USB port. Starts about $50 on Amazon. Great for mixing protein powders and liquid. Great for traveling or when you are just on the go. Although this is not dishwasher safe, it is easy to clean. Vitamix Systems
The product has been around since 1949. Prices range from $400-$720. Can make smoothies. An extended warranty is available. Ninja Systems
Ninja Fit 16 oz. Blender – Comes with two blender cups. Motor is 700 watts. One speed. Starts around $60. Nutri Ninja Pro 24-Oz. Blender – This is just for blending shakes. Motor is 900 W. Comes with 18 oz. and 24 oz. blender jars. One speed only. Starts around $100. Nutri Professional 3-Speed Blender – Comes with 72 oz. pitcher and 16 oz. cup. Price starts around $140. Ninja Auto-iQ Blender – There are several models that have the Auto-iQ cycle. This pauses through the cycle to allow food to fall towards the blades. These will have different speeds and may have both automatic and manual settings. Designed to make blended (“extracted”) smoothies using vegetables, seeds, nuts and fruits. Prices range from $120-$160. Magic Bullet/NutriBullet Systems
Magic Bullet is the original product in the line. The original can blend protein powders and fluids to create smooth protein shakes. Does a fairly good job pureeing soft, fresh fruit, canned or frozen fruit that has been thawed. Don’t expect the Magic Bullet to provide a completely smooth texture for blended or extracted smoothies. Motor is 250 watts. Starts at $40. Check to make sure whether you are buying a new or refurbished machine. NutriBullet Series comes in several models. Check websites and advertisements to find discounted prices. Most come with recipes. Check to see if parts are hand wash or dishwasher safe. NutriBullet (Original) – Eight or 12 Piece Sets. Starts around $80. Motor is 600 watts. NutriBullet Pro 900 – Nine to 15 piece sets. Starts around $100. Motor is 900 watts. NutriBulletRx – 10 piece set. Starts around $180. Motor is 1,700 watts. Has an extra heating feature to make soups or warm beverages. Could use other NutriBullets and heat product in microwave. This is larger than the original and Pro 900 machines. Other Smoothie Blenders:
Look for other personal blenders by Oster, Farberware and Elite. Immersion Blenders are hand-held blenders that you immerse in your cup or glass to blend. These can also be used to puree soft cooked vegetables and soups. More Options
Consider using a hand-held mixer to mix your protein powders and fluid together. Get a work out by using a whisk to blend the protein powder and fluid together.

Early vs Late Dumping Syndrome
Although different, the symptoms of early and late dumping syndromes are very similar.

They include:
Nausea or vomiting Abdominal cramps Diarrhea Sweatiness Dizziness Irregular heartbeats However, late dumping syndrome can also lead to low blood sugar.
Early dumping syndrome shows up 15-30 minutes after a meal. It occurs when food flushes too quickly through the gut. This could be because of eating too fast, not chewing well or drinking while eating.
Late dumping syndrome, on the other hand, happens when you eat a lot of refined sugars or extremely sweet foods. These concentrated sugars absorb water from the body as they pass through the intestines. After a few hours, they lead to a spike in hormones and a drop in blood sugar, making you feel dizzy and shaky.
Here are some foods that might trigger late dumping syndrome:
Cookies Candy Cakes Ice-cream Fruit juices Soda drinks Sweetened breads If you are experiencing late dumping syndrome, it is best that you speak with your registered dietitian to discuss what to eat after an episode and find the best solutions for your quick recovery.
How to Avoid Dumping Syndrome
Distribute your meals and snacks evenly throughout the day. Don’t drink and eat at the same time. Drink 15 minutes before and 30 minutes after eating to prevent flushing. Choose foods with less than 25 grams of total carbohydrates and less than 10 grams of added sugar. This is usually shown in the nutrition facts table on food packages! Make sure to eat protein at each of your meals and snacks. Protein stops sugar from passing too quickly through the gut. Be mindful of the amount of sweet foods and refined sugars you eat in a day. An entire box of cookies is different from 1 or 2 homemade cookies. A glass of juice from concentrate is far from a fresh smoothie made with whole fruits, milk and yogurt. Dumping syndrome can seem like an inevitable evil, but many patients are able to successfully avoid it. Well distributed meals and snacks made from wholesome, protein-rich foods is the way to go!
Written by: Nadeen Mekhael (Dietetic Intern)
– Lisa & Monica

You’re Starving, or Not
For some WLS patients, hunger goes away. For others, hunger is reduced enough so that you can keep it in check, even if you were constantly hungry before WLS. Some patients, though, still need to fight hunger. It is still a struggle to pass up certain foods and to keep portions small.
Your Head Gets Hungry
“Head hunger” is when you think you are hungry, but you are really just bored, the food looks good, or you feel like eating for some other reason. It is important to learn to recognize head hunger so that you know when it is not time to eat, but it is also important to realize that it may not be time to eat every time you are physically hungry. That is because you are losing weight, which means you are eating less than you burn, which means…your body is hungry.
Pizza and Ice Cream Taste Great
Often, your sense of taste changes after weight loss surgery. You may be one of the lucky patients who stops loving junk food. Pizza and French fries may be too greasy and salty for your new taste buds, and ice cream and muffins may be too sweet.
On the other hand, your taste buds may be just as enamored with the food groups of sweet, salty, starchy, and greasy. You may need to work just as hard as you did pre-op to keep pizza, ice cream, fried chicken, and bagels from overwhelming your diet.
Salads May Not Work
Your game plan for weight loss may include a huge salad once or twice a day. It is filling, healthy, and low-calorie – the perfect weight loss combo. The problem is that many weight loss surgery patients can no longer stomach salads for months or longer after surgery. Instead of lettuce, a protein, and some dressing, consider building your meals with cooked vegetables, a protein, and a small amount of healthy fat such as avocado or peanut butter.
Creativity Is the Name of the Game
Many other healthy foods may be off-limits because your tastes change or they are too stringy or they make you sick. You will have to be flexible to find healthy substitutes for them. Here are some common trouble foods and some alternatives.
Popcorn: try Protein Cereal as a quick snack.
Celery: opt for Bean Crisps
Lean beef and poultry: try fish, veggie burgers and other soy and bean products, and lentils.
Cheese: try peanut butter or hummus.
The good news is that most WLS patients tend not to develop aversions to vegetables, so pile your plate high!
What Happened to Water?
Water is the one calorie-free and free from cost food that is actually a nutrient…and it may have tasted great before surgery. Afterwards, not so much. Some patients have trouble drinking plain water after surgery. It just does not taste good anymore. Now that diet soft drinks and carbonated flavored water are off limits, you have fewer choices for hydration – but they are there.
Flavored water without bubbles.
Decaffeinated low-acid coffee and tea.
Ice water with lemon or lime.
Malnutrition Happens
Malnourishment may be far from your mind when your goal is weight loss, but it happens quite often. It can be a deficiency of protein, but also of vitamins and minerals. You will have to get enough protein every day and take your nutritional supplements every day, probably for life.
Sit Near the Bathroom
You just never know when you may need one when you sit down to eat a meal. Dumping syndrome strikes fast and without warning. By the way, you also cannot predict how full you will get and when you will be able to finish your entire plate.
You can make your weight loss surgery journey a tad easier by aware of what to expect, and there may be a few things your doctor does not tell you about.

Every time I sit down with someone to do their VSG and Bypass psych pre-op evaluation- they are understandably nervous and on edge. My first question is: "Has anyone explained to you the reason for why you need a psychological evaluation?" and there answer is always, "no, I have no idea why I am here."
I explain to them the reasons are threefold: 1) to make sure they understand the risks, benefits, and outcomes of the surgery, 2) to understand any psychological/behavioral ties to food that would benefit from behavioral recommendations/modification, and 3) to help the surgeon understand one's personality as it relates to a healthcare context, to better inform treatment.
1) Most people have been able to go over the risks, benefits, and outcomes with their medical team, but if not- I make sure last minute questions are addressed before they proceed.
2) During the evaluation- we talk about the patient's unique eating behaviors and how to modify them to help with maximum weight loss after the surgery. For instance, last week- I met with a guy who said he normally has a bowl of cereal at night in front of the TV and it provides him with a sense of "contentment." We talked about other ideas to create that same sense of contentment without sabotaging his weight loss surgery outcome, such as reaching out for support, taking a hot bath, listening to music, meditating, journaling, and/or creating a self-care ritual each night before bed.
3) The results of psychological testing provide me with really strong insight into each person's psyche as it relates to a medical setting. For instance, some results will say- " this person is uncomfortable talking about health care issues with strangers and may require more prompting than the average patient," or " this patient is likely to look compliant by being overly agreeable, but has a tendency to venture out on their own, and therefore frequent follow up is recommended," or " this person is uncomfortable in the patient role and will become increasingly agitated in the event of long-term health issues."
The 3rd piece of this evaluation is of concern to some, but for the most part- it is meant to help better inform their treatment plan. If a surgeon understands that a patient is more apt to look compliant but "go rogue," they are probably going to incorporate more frequent follow up to make sure that person has the best chance of success.
In the end- a psychologist's goal is not to be a hurdle in a patient's weight loss journey, but a catalyst.

Cooking methods. If you tolerated a saucy chicken pot-pie, it doesn’t mean roast chicken will go down just as comfortably. Dryer methods of cooking (like broiling, roasting, grilling, and pan-frying) tend to be more difficult to tolerate. Moist cooking methods on the other hand (like steaming, braising, stewing, simmering, poaching) that involve liquids or a sauce are typically better tolerated. Also, be careful when microwaving, as the process of reheating foods can dry them out. A good way to keep the moisture in is by resting the lid on the container (not sealed) and stir after each minute until ready. If you’re reheating dry foods remember to sprinkle in some water, broth, tomato juice, milk, or low-fat gravy to add additional moisture. Mechanical reasons like not chewing well enough and taking large bites. You should always be sure to cut your food into small pieces—as small as your pinky fingernail to start—and chew your food until it’s puree in your mouth before swallowing. Remember that digestion starts in the mouth! Emotional stress and anxiety can tighten the upper digestive system which makes food more difficult to tolerate. Do you find you eat more comfortably at home or on the weekends compared to at work? If so, your tolerance issues could be related to stress or anxiety. Always be sure to eat in a calm environment and start your meals by taking a few deep breaths to relax and decompress. Some patients feel more comfortable eating alone at first (i.e. in their office instead of in the cafeteria). Eating while multitasking! When you are eating, you should only be eating. We know that this is a tough one to practice, but eating while driving, watching TV, cleaning, working through lunch, etc. can distract you from taking small bites and chewing well. Do your best to put away distractions during meal times. If you choose to eat lunch in your office, mute the volume on your computer and turn off the monitor so you’re not tempted to check your email in between bites. Posture. It sounds silly to discuss, but it’s true, poor posture can negatively affect digestion. If you are eating while slouched or reclined on the couch or awkwardly propped up on pillows in bed, chances are that you will experience some tolerance issues. When you are eating, you should ideally be sitting in a chair pulled close to the table with your bum as far back as possible and with your back nice and straight. Eating at the table in your kitchen or dining room will also give your meals and snacks more structure. Generally speaking, it’s a good habit to limit food and eating to only the kitchen and dining room. Excerpt from "The Complete Guide to Weight Loss Surgery: Your questions finally answered".
Available on Amazon.com, Amazon.ca, or our website (PDF download).

Key Points:
· Having your own food with you helps you stay on track with your nutrition.
· Foods that need to stay cool will need some type of cooler, insulated lunch bag or ice pack.
· Bringing leftovers may require heating, so look for containers that are safe for microwave cooking.
Lunch Bags
· The size of your lunch bag will depend on how many meals and snacks you need for your day.
· Insulated lunch bags can keep food cold for longer periods of time if you don’t have a refrigerator available.
· You can buy reusable ice packs to put in your lunch bag.
· A reusable lunch bag is environmentally friendly and you can use this for years.
· The size will be determined by how many meals and snacks you need for the day.
· Neoprene lunch bags can be put in the washing machine and dryer.
Cooler
· Great to have when driving around for work or when traveling. Pack with ice, load with your protein drinks or other protein foods.
· Coleman and Igloo are the classic brands, but others are available.
· Coolers now come in hard and soft side versions. There are coolers you can carry, sling over your shoulder, carry as a backpack or roll behind you.
Mini-Fridge
· If your workspace does not have a refrigerator that is convenient to get to, consider buying a mini-fridge to stash protein drinks, leftovers and snacks. Check with your employer for guidelines. Certain electrical outlets may limit the type of mini-fridge you can bring to work.
Plastic Containers
· Find plastic containers with lids to bring your food in measured quantities.
· Some plastic containers can also be microwaved.
· Look for 2 oz., 4 oz. (1/2 cup) and 8 oz. (1 cup) servings. This size you need depends on how far out you are from surgery.
· Tupperware, Rubbermaid, Ziploc and Glad are available brands. Look at discount stores for smaller containers.
Bento Boxes
· Look for Bento box for kids on Amazon. These are boxes that are divided to separate food. You can measure your portion into the sections. The kid-size has portion control for bariatric patients. Bento boxes also available on The World According to Eggface blog.
Stackable Containers
· GoStak is a product the dietitians found at Obesity Week 2017. There are four containers that range from 2 to 5 ounces. They twist together to form a column. You can find it on www.blenderbottle.com. It is also on Amazon.
· Described on the website: “Durable jars secure tightly to carry powders, vitamins, supplements, snacks and more.”
· They are BPA free and dishwasher safe.
Travel Cups/Mugs
· Designed to fit in cup holders in your vehicle. These usually have a small opening on the side to sip from. Helps to avoid straws.
· Grocery stores now carry disposable hot beverage cups with lids. This would be great way to sip warm broth or a high protein warm cocoa. Warm up a chocolate protein shake and hit the road.
Insulated Tumblers, Cups and Containers
· Insulated cups can keep your protein drinks cold or hot. Look for double-sided cups.
· Thermos is a brand that has been around for decades. There are water bottles and other food storage items available.
· YETI is a brand that is popular. It is more expensive, but it is a double wall, heavy gauge, stainless steel product. You can find a 20 oz. tumbler with lid for $29.99 at Academy, Gander Mountain and Cabela’s. A less expensive brand is Ozark Mountain at Walmart. A 20 oz. Ozark Mountain metal tumbler is about $10.
· S’Well is another brand that comes in a lot of styles and colors. Prices around $35. Part of the money you pay helps S’Well help provide clean drinking water to children around the globe through the U. S. Fund of UNICEF.
· MyHydrate is a water bottle that has a built-in reminder to help you remember to sip your water. It’s $40.
· There are other insulated containers for hot foods like soups and stews.
Serving Plates, Bowls and Utensils
· You can find a variety of styles.
Warmers
· Crock-Pot makes an electric lunch crock that has a 20 oz. capacity. Prices range from $20-$30. One reviewer recommends to turn it off about 45 minutes before your lunch, because even the low setting can be too hot. This would be great if splitting a meal with a co-worker or family member.

1. My weight does not determine my success nor worth.
“If you accept your personal best at everything else in life, why not weight?” – Yoni Freedhoff
Isn’t that SUCH a good quote?
Is your WLS team happy with your progress, but you aren’t? Why are you still pushing for and obsessing over those next 10 lbs? Reflect on why you feel that you must lose those extra pounds and what will happen if you don’t?
2. I acknowledge that a healthy lifestyle (i.e. eating healthy most of the time and moving my body often) is a part-time job. Some weeks it doesn’t feel like work, but often it does.
It is important to accept that doing well after WLS is not an accident. You have to make the time for your new habits.

3. I see meal planning, grocery shopping, and cooking as acts of self-care.
This mindset shift is HUGE. Embracing this shift requires practicing gratitude. For example, this means being able to acknowledge that although you may not enjoy cooking, you are thankful to have food to put on the table. Or, as another example, maybe you don’t enjoy meal planning, but you can acknowledge how much smoother getting organized on the weekend makes your week flow.
Try viewing these chores from a place of gratitude this week, and watch how much lighter they all of sudden feel.

4. I move my body because it feels good and helps me to re-charge. I don’t exercise to control my weight.
If you are exercising solely for the purpose of controlling your weight, it is only a matter of time before you burn yourself out.
Moving your body should come from a place of self-care. The activities that you choose should be enjoyable and energizing. They shouldn’t feel forced.

5. I am not on a diet. I eat foods that I enjoy. I practice moderation and flexible eating to the best of my ability.
All foods fit.
If you feel restricted, if you’re counting your calories daily, if you’re always hungry, or if you often feel guilty or ashamed about your food choices, you are going to burn yourself out!
If you have dieted for most of your life, you likely have a lot of baggage in this department to work through. For many of our patients, it takes years to work through this mindset shift, so don’t be too hard on yourself.

So, how many of these mindset shifts have you fully embraced? Which ones are still a struggle? Where do you feel stuck?
Try posting these 5 mindset shifts up in your office or home to keep them top of mind as you go about your day. Envision and journal about what it would feel like and look like to embrace all of them.
Click HERE for a FREE printable of these 5 mindset shifts!
Click HERE to read more about this kind of content.
Click HERE to follow our Facebook page for up-to-date videos and nutrition information.
If you need help working through these shifts, speak with your WLS dietitian or psychologist.
Wishing you all much happiness in your WLS journey!
– Monica & Lisa

Why Does It Matter?
There is an expression that goes, “Shoot for the stars and you’ll hit the moon.” The idea is that if you set your sights high but fall short, you will still achieve something great. The theory may sound good, but it may neglect to consider reality.
The truth is that for many of us, another saying is truer: “Success breeds success.” That is, when you hit one goal, you are motivated to keep working towards your next one. You build momentum as you hit goal after goal, and those goals then act like stepping stones to those proverbial stars.
The Trap of “Too Much, Too Fast”
There is a common tendency overshoot when it comes to weight loss goals. These are some reasons why.
We want to lose weight so badly that we think only of the dream goal.
Most of us tend to think of ourselves as above average – so we set our weight loss goals at higher than average.
We set deadlines that are too short because we are so focused on getting there that we forget to recognize how wonderful the journey is.
We set our goals based on what someone else lost.
Classic Failure: “All or Nothing”
One of the surest ways to set yourself up for failure is to set your weight loss goal to be too many pounds within too little time. It is comparable to the “all-or-nothing” mentality that so often comes with dieting: you are doing fine until you eat a cookie, and then you figure that the day is wasted, so you might as well finish the bag of cookies, skip your workout, and order pizza and breadsticks for dinner.
The same mentality after weight loss surgery can get you into the same trouble. If you aim for an unrealistic 20 or 30 lb. in your first month and instead hit a respectable 5 to 10 lb., the “disappointment” can discourage you so you do not try as hard.
Realistic Weight Loss
The amount of weight you can realistically expect to lose depends on your procedure, how much you have to lose, and your own drive and other individual characteristics. An average gastric bypass or sleeve patient might lose about 50% of excess weight. For example, Someone who is 5’4” tall and weighs 245 lb. has about 100 lb. of “excess” body weight and might set a goal to lose about 50 lb.
Another way to look at it is to take a rough estimate of average weight loss with your procedure for your surgeon’s patients. You might use that number as the basis for your own weight loss goal. You could also look at your final goal – say, 100 lb. down – and divide that by 1 to 2 years – in this case, a seemingly modest 1 to 2 lb. per week.
Setting Realistic Goals
For weight loss or any other goal, you can follow certain guidelines for realistic goal-setting. Set your goal to:
Include a realistic amount of weight loss.
Leave yourself enough time to achieve that amount.
Include interim goals that you can celebrate and use as motivation.
Provide for rewards as you progress, so you stay motivated.
Allow enough time for plateaus and setbacks. They will come.
Keep It in Perspective
Strange but true…weight loss is only one of many reasons to get weight loss surgery and follow a healthier lifestyle. What about…?
Gaining energy?
Getting healthier?
Feeling more confident?
Participating in more of life?
Along with setting weight loss goals, you can set other goals for healthy eating, working out, and trying new things. You will always have something to chase after and you will be able to see more progress every day.

Consider Macros
That is, “macronutrients,” or carbohydrates, fat, and protein. The news is bad on the surface since the average fast food meal has more carbs and less protein per calorie than the average home-cooked meal. You can work to turn this around, though.
Carbohydrates: Cut back on carbohydrates by skipping the starchy sides: French fries, potato chips, and hash browns, steamed, fried, or Mexican rice, and breadsticks. Try to go “green” (lettuce wrap) or “naked” (no wrap) with your burger, tortilla, or sandwich; if the fast food joint cannot honor your request, just eat the filling with a knife and fork, and throw away the bread, bun, tortilla, or taco shell (if you are feeling guilty because of starving children in third-world countries, make a donation. You’ll do more good than you would by adding starch to your hips).
Protein: How can you boost your protein intake at a fast food restaurant to be what you need? Skinless grilled or baked chicken, lean cold cuts, cheese, and beans can all up your totals, and yogurt is an increasingly common side option. Even a small burger patty can give you 10 to 15 grams of protein, although it comes with a few extra grams of fat.
A good protein goal for a meal is about 20-30 grams. You can get that for 200-300 calories with any of the following.
Burger King Double Cheeseburger, no bun; Grilled Chicken Garden Salad, no croutons; or Veggie Burger with cheese, no bun or mayo. McDonald’s Grilled Southwestern Chicken Salad, no cheese; or Grilled Chicken Sandwich, no bun or spread. Taco Bell 2 grilled or fresco steak soft tacos, no tortillas; chicken or steak Power Menu Bowl, no rice or cheese. KFC Grilled Chicken Drumstick plus green beans or side salad. Panda Express Grilled Teriyaki or Asian Chicken. Fats: Your first order of business is to avoid anything fried. You will be avoiding excess grease while also avoiding sneaky carbs in breading – did you know that the amounts of carbs in onion rings and fried chicken are comparable to the amounts in bread? Also, watch the fatty spreads – think mayonnaise – salad dressings, and dips.
Find the Vegetables
Protein and vegetables…does this sound familiar? It should, since your goals when eating at a fast food restaurant should be the same as when you eat at home. Vegetables help fill you up without filling you out, and it is best to eat as many of them as you can handle with your pouch or sleeve. It may take a little more digging to find vegetables at fast food restaurants than at home, but you can usually do it. Here are a few leads.
Ask for extra lettuce, tomatoes, and any other available vegetables on burgers and sandwiches. Order a side salad or baby carrots with your meal. Check for salads with grilled chicken as an entrée. Pile salsa and diced vegetables onto your naked burrito. When “Value” Isn’t
Besides the convenience, the deals are among the most tempting things about fast food. For pennies more, you can often add fries and a drink, or you could get a second burger or taco for half the price. Don’t do it!
“Value” depends on what you want and need; why would you pay extra, even if it is “only pennies more,” for extra fat, sugar, starch, and calories? A healthier definition of “value” might be to pay the least you can for a meal that is convenient, delicious, and healthy. Why include “oversized” in your definition?
For those times when fast food simply makes sense, go for it – just keep yourself on track by reading the menu carefully and staying focused. You can do it, no matter where you end up. You might as well enjoy it!