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Hello... I thought I would post this must read article by the surgeon who invented the "Green Zone" and how the band should "ideally work".... http://bariatrictime...1/#comment-2133 Gastric Banding and the Fine Art of Eating BT Online Editor | September 22, 2011 by Paul O’Brien, MD Dr. O’Brien is from the Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia. Bariatric Times. 2011;8(9):18–21 Funding: No funding was received for the preparation of this article. Financial Disclosure: Dr. Paul O’Brien is the Emeritus Director of the Centre for Obesity Research and Education (CORE) at Monash University, which receives a grant from Allergan for research support. The grant is not tied to any specified research projects and Allergan has no control of the protocol, analysis and reporting of any studies. CORE also receives a grant from Applied Medical toward educational programs. Dr. O’Brien has written a patient information book entitled The Lap-Band Solution: A Partnership for Weight Loss, which is given to patients without charge, but some are sold to surgeons and others for which he receives a royalty. Dr. O’Brien is employed as the National Medical Director for the American Institute of Gastric Banding, a multicenter facility, based in Dallas, Texas, that treats obesity predominantly by gastric banding. Abstract The author reviews the physiology of eating and what the adjustable gastric band does to the function of the distal esophagus and upper stomach of the patient. The author also provides the “Eight Golden Rules” on proper eating habits for patients of laparoscopic adjustable gastric banding, including what, when, and how they should eat, in order to achieve optimal weight loss results. Introduction Laparoscopic adjustable gastric banding (LAGB) has been shown to enable patients with obesity to achieve substantial, durable, and safe weight loss,[1,2] which can help reduce or resolve multiple diseases,[3] improve quality of life, and prolong survival in patients with obesity.[4] LAGB is a weight loss surgical procedure performed solely for the purpose of affecting a key physiological function in weight loss, appetite control. In 2005, we conducted a randomized, blinded, crossover trial that showed that the LAGB controls the appetite.[5] However, if the LAGB is not placed properly or if the patient does not eat properly, it will not perform at an optimal level. For example, if the band is placed too loosely, then it will not provide the proper level of reduced satiety and appetite, and likely will have little effect on the patient’s weight and health. If the band is placed too tightly or if patient eats too fast or takes large bites of food, slips and enlargements can occur, leading to reflux, heartburn, vomiting, and sometimes the need for revision. Optimally, the band should be adjusted so that it squeezes the stomach at just the right pressure. If the patient eats correctly and the band is placed correctly, the LAGB should adequately control the patient’s appetite, resulting in optimal weight loss. The Physiology of LAGB Dr. Paul Burton, a bariatric surgeon at the Centre for Obesity Research and Education, Melbourne Australia, has studied the physiology and the pathophysiology of the LAGB closely. He used high-resolution video manometry, isotope transit studies, endoscopy, and contrast imaging to understand what happens during eating in normal controls, eating in patients who are doing well after LAGB, and eating in patients who have symptoms of reflux, heartburn, and/or vomiting after LAGB.[7–15] In Burton’s series of articles, he concluded that in LAGB, it is not the band that fails, but rather the patients who receive the band and, more importantly, the doctors who care for them. Many years ago at the Centre for Obesity Research and Education (CORE), my colleagues and I developed the Green Zone chart, a conceptual way of identifying the optimal level of band restriction (Figure 1). When a patient is in the yellow zone, it is an indication that the band is too loose. When in the yellow zone, a patient may be eating too easily, feeling hungry, and not losing weight. When a patient is in the green zone, he or she does not feel hungry, is satisfied with small amounts of food, and is achieving weight loss or maintaining a satisfactory level of reduced weight. When a patient is in the the red zone, it is an indication that the band is too tight. The patient experiences reflux, heartburn, and vomiting. The range of food the patient in the red zone can eat after undergoing LAGB is limited and he or she may start to eat abnormally (so-called maladaptive eating), favoring softer, smoother foods like ice cream and chocolate. While in the red zone, patients will not lose weight as effectively and they may even gain weight. Burton measured the pressure within the upper stomach beneath the band in numerous patients when they were in the green zone. He found the optimal pressure was typically 25 to 30mmHg. The art of adjustment is to find the level of Fluid in the band that achieves that pressure range. That level of pressure generates a background sense of satiety that persists throughout the day. The patient, when correctly adjusted, normally will not feel hungry upon waking in the morning, and throughout the day should feel much less hungry than he or she did before band placement. In my experience, it is common for LAGB patients to have no feeling of hunger in the morning. Then, during the day, a modest level of hunger will develop, which a small meal should satisfy. One of the key lessons learned from Burton’s studies was that each bite of food should pass across the band completely before another bite is swallowed. There is no pouch or small stomach above the band and there should never be food sitting there waiting. The esophagus is a powerful muscular organ that typically generates pressures of 100 to 150mmHg, but it is capable of generating pressures above 200mmHg. Esophageal peristalsis squeezes the bite of food down toward the band and then progressively squeezes that bite across the band. Each bite must be squeezed across the band before the next bite starts to arrive. Figure 2 shows a bite in transit across the band. A single bite of food, chewed well until it is mush, will move down the esophagus by peristalsis. At the level of the band, the esophageal peristalsis will squeeze that bolus of food across the band. It takes multiple squeezes (usually 2–6 squeezes or peristaltic waves) to get that bite of food across in a patient with a well-adjusted band (Figure 2). Those squeezes generate a feeling of not being hungry and stimulate a message that passes to the hypothalamus to indicate that no more food is needed. If a single bite of food is able to generate between two and six waves of signal, a meal of 20 bites may generate 100 or more signals. This is enough to satisfy a person and is enough to signal him or her to stop eating. We recognize two terms for appetite control, satiety and satiation. Satiety refers to the background control of hunger that is present throughout the day regardless of eating. In the LAGB patient, satiety is generated by the band exerting a constant compression on the cardia. Satiation is the early control of hunger that comes with eating. In the LAGB patient, satiation is generated by the squeezing of the bolus of food across the band during a meal. Each squeeze adds to the satiation signal. There are sensors in the cardia of the stomach that detect this squeezing. The exact nature of these sensors is still to be confirmed but they must be either hormonal or neural. We know that satiety and satiation are not mediated by one of the hormones currently known to arise from the upper stomach.[16] Ghrelin is a hormone that stimulates appetite. A number of hormones that can be derived from the cardia of the stomach are known to reduce appetite. None of these hormones are found to be raised in the basal state after gastric banding and none can be shown to rise significantly after each meal.[16] Vagal afferents are plentiful in the cardia, and one group of afferents has a particular structure that lends itself to recognizing the compression of the gastric wall associated with squeezing of the bite of food across the band. In my opinion, the intraganglionic laminar endings, better known as IGLEs, are the most likely candidate as mediator of the background of satiety throughout the day and the early satiation after a meal. The IGLEs lie attached to the sheath of the myenteric ganglia and are known to detect tension within the wall of the stomach. They are low-threshold and slowly adapting sensors and therefore are optimal for detecting continued compression of cardia of the stomach over a 24-hour period. The several squeezes that go with the transit of each bite stimulate the IGLEs further. The signal passes to the arcuate nucleus of the hypothalamus and the drive to eat is reduced. The lower esophageal contractile segment. Burton developed the concept of the lower esophageal contractile segment (LECS). It is made up of four parts: the esophagus, the lower esophageal sphincter, the proximal stomach (including the 1cm or so above the band and the 2cm of stomach behind the band), and the band itself (Figure 3). As the esophagus squeezes the bolus of food down toward the band, the lower esophageal sphincter relaxes as this peristaltic wave approaches. It then generates an after-contraction, which can maintain some of the pressure of the peristaltic wave as a part of the food bolus is squeezed into that small segment of upper stomach. The upper stomach, including the area under the band, is sensitive to these pressures. It generates signals to the hypothalamus. These signals may be hormonal but are more likely to be neural. A correctly adjusted band will generate a basal intraluminal pressure of 25 to 30mmHg, providing a resistance to flow. The segment of the bolus that is squeezed through generates more signals from that area. Keeping the LECS intact is a key requirement for success with the gastric band. Bad eating habits (e.g., insufficient chewing, eating too quickly, taking bites that are too large) hurt the LECS. If those bad habits go on for long enough, stretching occurs and the power of peristalsis is lost, leading to the return of hunger (Figure 4).[11,12] The Fine Art of Eating A quality aftercare program is essential to successful weight loss in patients after LAGB. Before making the decision to proceed with LAGB in patients, I promise my patients three things: 1) to place the band in the optimal position safely and securely, 2) that they will have permanent access to a skilled aftercare program, and 3) that I will give them the information they need to obtain the best possible weight loss from the band. In return, I ask for three commitments from my patients: 1) that they follow the rules regarding eating after undergoing the procedure, 2) that they follow the rules regarding exercise and activity, and 3) that they always come back for follow up no matter how many years have passed.[6] The “Eight Golden Rules.” At my facility, we summarized guidelines for eating after LAGB into what we call the “Eight Golden Rules” (Table 1). These rules are included in a book and DVD given to every patient who undergoes LAGB at the facility.[6] The rules are also posted on www.lapbandaustralia.com.au and are reinforced at most aftercare visits. These eight golden rules must become part of each patient’s life. The effect of the LAGB procedure on hunger facilitates a patient’s adherence to the rules, making it more likely that he or she will follow them. However, achieving positive results with LAGB requires a working partnership between the physician and patient. Adhering to these rules is the patient’s part of the partnership, and he or she ultimately is responsible for the success or failure of weight loss following LAGB. What to eat. After undergoing LAGB, patients should eat small amounts of “good food,” meaning food that is Protein rich, of high quality, and in solid form. Each meal should consist of 125mL or 125g (i.e., about half of a cup of food). This measure of “half a cup” is a concept rather than a real measure of food, as some foods, such as vegetables and fruit, are composed largely of Water and this has to be allowed for in some way. Thus, I allow exceeding the “half a cup” limit a little for vegetables and fruit. We instruct patients to put each meal on a small plate and to use a small fork or spoon. The patient should not expect to finish all of the food on the plate, but rather he or she should plan to stop when he or she is no longer hungry. Any food left on the plate should be discarded. Protein-rich foods. Protein is the most important macronutrient in the food a LAGB patient eats. At our clinic, we recommend that our patients consume approximately 50g of protein per day. We have measured protein intake of our patients (Table 2) and have monitored their blood levels. We have not seen any protein malnutrition after LAGB, indicating that a daily intake of about 50g a day is sufficient. Table 2 shows the energy and macronutrient intake of 129 consecutive patients measured before and at one year after LAGB. Note the mean energy intake is reduced by approximately 1500kcals.[17] The best source of protein is meat; however, red meats, such as beef and lamb, tend to be difficult to break up with chewing in order to be sufficiently turned into mush. It is much easier to break up fish with chewing, and many fish are high in protein, including shellfish. chicken, duck, quail, and other birds can also be cooked to be easily chewed to mush before being swallowed. eggs and dairy, including cheese and yogurt, are also excellent protein sources. For nonanimal sources of protein, a patient should consider lentils, chickpeas, and Beans. Half of the “half a cup” allotment per meal should comprise protein-rich food. The other half should be made up of vegetables and/or fruits. I recommend to my patients that they eat more vegetables than fruit because vegetables have less sugar. Any space left in the “half a cup” can be used for the starches, (e.g., bread, Pasta, rice, cereals, potatoes), though I recommend to my patients that they eat a minimal amount from this group of foods as they tend to provide no important nutritional benefit. High-quality foods. High-quality food are foods that are minimally processed, natural, and whole. We encourage our patients to look for quality over quantity—for example, they might try sashimi-grade tuna, smoked salmon, duck breast, lobster, or even a simple poached egg. It is also important to remind your patients that there is no limit to the amount of herbs and spices that can be used to enhance the flavors of their foods. Solid foods. The patient should choose solid foods over liquids whenever possible. Liquids pass too quickly across the palate and, more importantly, too quickly across the band. There is no need for the esophagus to squeeze liquid, and without the squeeze, there is no stimulation of the IGLEs and no induction of satiety; therefore, eating calorie-containing liquids may negatively impact a patient’s weight loss. When to eat. After undergoing LAGB, a patient should eat three or less times per day. If the patient is in the green zone, meaning that the band is adjusted correctly, there should be no need for him or her to eat between meals. In fact, even three meals a day may be more than needed for satiety. In my experience, patients have little interest in eating in the morning. By late morning or early afternoon, patients may start to notice some hunger, which indicates that it is time to have a first small meal. In the evening, patients may have another meal. Most importantly, patients should be instructed that a meal missed is not to be replaced later on. The typical human body is satisfied with a maximum of three meals per day but often is happy to accept two or even one meal per day. Patients should be reminded that there should be no snacking between meals. If a patient finds that he or she is hungry by late afternoon, encourage him or her to eat something small and of high quality, such as a piece of fruit or some vegetables, just to tide him or her over until the evening meal. The patient should then visit the clinic to check whether or not he or she is in the Green Zone. It is important that the patient adhere to the aftercare program to monitor whether or not he or she is in the green zone. If not in the green zone, the patient will need to have fluid in the band increased or decreased. How to eat. Take a small bite and chew well. The “half a cup” of food should be placed on a small plate. The patient should use a small fork or a small spoon to eat. A single bite of food should be chewed carefully for 20 seconds. This provides the opportunity to reduce that bite of food to mush. It also provides the important opportunity for the patient to actually enjoy the taste, the texture, and the flavor of the food. Encourage your patients to enjoy eating more than they ever have. After chewing the food until it is mush, the patient should swallow that bite. Swallow, then wait a minute. The patient must wait for that bite to go completely across the band before swallowing another bite. Normally, it will take between two and six peristaltic waves passing down the esophagus, which can take up to one minute. This is probably the biggest challenge of educating the patient who has undergone LAGB. You must instruct the patient to eat slowly—chew well, swallow, and then wait one minute. A meal should not go on for more than 20 minutes. At one bite per minute, that is just 20 small bites. The patient probably will not finish the “half a cup” of food in this time. In this case, the patient should throw away the rest of the food. After undergoing LAGB, the patient should always expect to throw away food and to never eat everything on the plate. If it takes between two and six squeezes to get a single bite of food across the band and each squeeze generates satiety signals, then 20 bites should be generating 40 to 120 signals. The actual number will depend on the consistency of the food, the tightness of the band, and the power of the esophagus. With good eating practices and optimal band adjustments, the patient should not be hungry after 20 bites or less. As soon as the patient is no longer hungry, he or she should stop eating. After undergoing LAGB, the patient should never expect to feel full. Feeling full means stasis of food above the band and distension of that important part of the LECS above the band. This destroys the LECS, the mechanism that enables optimal eating behavior and appetite control. A patient should always keep this process in mind. If the patient finds that after eating the “half a cup” of food he or she is still hungry, he or she should review his or her eating practices, correct the errors, and consider the need for further adjustment of the band. If this is occurring, it is usually an indication that the patient is not in the green zone. Eat a small amount of good food slowly. These eight words are the key to success. Small amount refers to small bites, the small fork (e.g., oyster fork), and a total meal size of half a cup. Good food refers to protein-rich, high-quality, and solid food. Slowly refers to chewing well, swallowing, and waiting a minute. Try to repeat these eight words to every patient every time you see them. Get them to repeat it at every meal. The failure of the gastric band can almost always be traced to failure of this process. Addressing the Challenges The two principal challenges after LAGB are weight loss failure and the need for revisional surgery due to proximal enlargements above the band. Weight loss failure will occur if the band is not placed or adjusted correctly or if the patient does not adhere to the guidelines of proper eating and exercise. When a patient is not achieving results after his or her LAGB operation, the doctor should check to ensure that the band is correctly and safely placed. The most common reason for weight loss failure is poor eating behavior, which leads to enlargement above the band. There are three common eating errors: 1. The patient is not chewing the food adequately. Food must be reduced to mush before swallowing. If it cannot be reduced to mush, it is better for the patient to spit it out (discreetly) than to swallow it. 2. The patient is eating too quickly. Each bite of food should be completely squeezed across the band before the second bite arrives. 3. The patient is taking bites that are too big to pass through the band. Each of these errors leads to a build up of food above the band where there is no existing space to accommodate it (Figure 4). Space is then created by enlargement of the small section of stomach or by enlargement of the distal esophagus, both of which can compromise the elegant structure of the LECS. If the LECS is stretched, it cannot squeeze. Without the squeezing, satiation is not induced. When satiation is not induced, hunger persists, more eating occurs, and stretching continues. If our patient continues this each day for a year, it is inevitable that chronic enlargement will occur, the physiological basis for satiety and satiation is harmed, and stasis, reflux, heartburn, and vomiting supervene. The doctor should continually review the Eight Golden Rules for proper eating and exercise with each patient. For optimal weight loss following LAGB, the patient should have access to a comprehensive long-term aftercare program for clinical support and optimal band adjustments and he or she must follow the guidelines regarding eating and exercising for the rest of his or her life. “Eat a small amount of good food slowly” is the key to optimizing the gastric band.

You might want to talk to a nutritionist about appropriate substitutions if you have food allergies, mamaje. If you don't have one already, it might be worth the cost of an appointment to ease your mind and have some closure on that concern. As for eventually being able to go out and enjoy things with your family and friends again, of course you will. Hopefully you will have embedded your good habits by then that you'll really want that grilled salmon with sauce on the side and the veggies that go with it, and won't care to have that giant mega-burger with 4 kinds of cheese, onion rings and a big shake. The goal is to build good habits so that if you choose to have a treat, it will be just that, and you'll do so in an appropriate way. It really depends a lot on you, and your long-term relationship with food. For example, I don't particularly have a sweet tooth, though I enjoy an occasional small dessert or a cookie in moderation even now, pre-sleeve. I fully expect that once I get past the first few months I might have the occasional tiny piece of pie or small piece of dark chocolate, because I'm easily satisfied with just a taste. I *DO* have a problem with salty Snacks like crackers, chips and popcorn. I may never allow those back into my diet, because it just won't be worth it if they sabotage me. There are things I can substitute that will likely serve me better nutritionally and fill me up on a more appropriate serving size, like raw veggies with a non-fat Greek yogurt dip.

Hello. I am a month out (yesterday) from gastric bypass. I have had a very difficult time getting fluids and food down since surgery. I have gone twice for fluids due to becoming dehydrated. My Dr. has me on nausea medication that helps some. I'm struggling the last few weeks with throwing up even if I'm not nauseated. I've thrown up Fairlife milk, chicken broth, Greek yogurt, applesauce, even Popsicles from time to time. Anytime I put food or liquids in my stomach, I feel heavy and bloated. Has anyone dealt with this? Did it get better quickly? I'm barely eating more than 3-5 Wheat Thins a day and drinking Gatorade. I'm miserable and am not sure what to do.

An insulated lunch box with a cold pack in it.. put yogurt and cottage cheese and protein shakes in it. Thermos for hot soup...

I am 11 months post surgery and still have a Protein shake or fortified greek yogurt almost every day. I am not a huge fan of meat and I am allergic to soy, so I need the whey protein from the shakes to ensure I get my 60 grams each day.

I am on the full liquid diet now. My dietician gave me a list of 5 things I can have. Most before surgery were great, but with the change in my stomach I can't eat them all now. Her list is skim milk, strained soups made with skim milk, sugar and fat free pudding or yogurt, protein supplements, and no ice cream. So wait.....that's really only 3 things. Please help me!!!! What was or is your favorite thing to eat on the full liquid diet???? I'm going crazy!

How often do you east after surgery. I'm about a week out and was curios because today I had maybe ounce and half a yogurt. Maybe t three ounces broth and water watery water.

My light bulb moment happened this week. I had my surgery on November 22 and have done pretty well. I have stayed the course and have not swayed from my list of acceptable Protein options prior to this mini vacation. This week I went to San Francisco to care for my aged father. When I arrived in SF I went to the market immediately and bought my Dannon light and fit yogurt, cottage cheese, Light Baby Bel cheese and turkey slices before I even went to my Dad's. I wanted to make sure I continue to make good choices when it came to food. Seven days later....... I am home and food wasn't an issue. For the first time in decades I took control of my eating habits when visiting the family in San Francisco. I said NO to a cannoli, NO to a Joe's hamburger, NO to a Tostada, NO to a crepe, etc.......my response was, "Can I meet you afterwards?" I always carried a Baby Bel Cheese in my purse and always felt satisfied. I came home 4 pounds lighter and the feeling........I GOT THIS!

I was very much a sweets lover and chips and pasta and bread and alllllll the things you can't eat for at least six months after your surgery lol. I actually stopped eating all that stuff months before I even had my surgery so despite the fact I'm only four months post op, it's been close to a year since I've had most of that stuff. Do I miss it? Kinda. But honestly, your taste buds do change and you'll find enjoyment in foods you perhaps didn't appreciate as much or even like before! I loooove my yogurt in the morning. And sometimes at night lol. I find that's actually the thing I crave the most and I kinda get my sweet fix from it. Also, sugar free pudding gets me my chocolate fix when the store is out of my chocolate protein drinks lol

I am having yogurt.. It's okay.. But I think the problem is when you constantly eat the same things over and over and over.. NOTHING TASTES GOOD...

Mine was April 25 and I've not been hungry. Forcing myself to drink protein shakes and today, I added yogurt. I was told after two weeks, I could introduce soft foods...eggs, tuna, etc.

Try something like thin mashed potatoes (regular or sweet), or creamy polenta. Everybody is different, but you are allowed yogurt and puddings (at least I was) in the liquid stage. I also found homemade chicken broth with farina made a nice soup/stew and varied it up. I could handle that stuff more than I could a scrambled egg. You can get creative, just start really small and make sure your stomach can handle it. DON'T GO FOR THE HAMBURGER. It sounds tempting, but you will regret it. Your stomach is extremely sensitive, and you need to go slow when you start introducing foods or you will get very sick (not a pleasant experience). The last thing you want to do is go under the knife to fix a leak because you gave into the craving. I am 6 months out, and its be best decision I ever made (and now I can eat hamburger, well a mini one!)

I eat greek yogurt for breakfast or a protein bar. The pure protein are about 180 to 200 calories but they have sugar alcohols that can cause stomach upset and gas. I limit those to about 1 a week. I eat tuna, boca burgers, black bean burgers, cottage cheese, low sodium V-8 because I dont always eat my veggies, I make black bean casserole. Edamame with sea salt, sometimes but rarely chicken salad and I do not do low fat or fat free anything because the amount of fat I eat in a day is not too much. I also buy any of the pic sweet veggies in the single serving size. Protein shakes I am done with. I don't think at a certain point you should still drink them. It is liquid calories and they do not keep you full. I eat eggs for breakfast too with a small amount of ketchup to help them go down. I hardly eat any meat because it doesnt like me. There are many things you can eat you have to try them. I thought I would never eat tofu but I love it. Sauteed in cabbage it is so good with lots of different seasoning such as dill, seasoning salt, cracked pepper. Packed with protein and taste like whatever you cook it with.

Yes I'll be starting my pre-op diet in a couple of weeks, so I'm trying to gather as much information as I can, so I thank you for your replies. I love yogurt, I've never had the Greek yogurt, but I'm sure with the shake it will be a lot better. Thank you!

I have Celiac and was sleeved 11 months ago. One of my favorite foods is Subway????. I order a turkey sub without the bread. They put it in a salad bowl for me and I eat it with a knife & fork. Greek yogurt, string cheese and turkey bites are a staple for me. I don't eat bread at all, even gluten free. Doesn't go down or sit well????

My problem for the past few days is that everything is either so bland, or I'm just getting sick of the foods/textures that I can ingest. I just read up on a few things online for changing the flavors of broth and yogurt and decaf coffee.... vanilla Extract, Cinnamon, Nutmeg, or Ginger: add to yogurt, coffee, or chocolate/vanilla Protein shakes to change up the flavor Garlic powder, pepper, salt substitute (for low or no sodium broths), chili powder, cumin, thyme, rosemary, basil, paprika, hot sauce, lemon juice, or soy sauce: add to your broth to make it less bland. Don't worry about putting too much - it normally takes at least a tablespoon of any of those (except the salt) to help 14oz fat free/low sodium broths have taste. Hope it helps - I know I can't wait to try them.

I will tell you, if I was eating a puree of chicken, green peas, and pumpkin--I'd be a Starvin' Marvin all the live-long-day. Rinse and repeat. I was starving after my RNY despite pretty strict adherance to my diet--until I was able to advance to soft food/purees. And then I still didn't feel full until I was able to progress to more dense proteins. BUT, I did not add insult to injury like I see so many on here do. I did NOT eat refried beans, nor mushy peas, nor pumpkin/sweet potato/butternut squash/lentils or any other legume. Had I done that, my insulin (which was still in the teens--way too high) would have stayed up and my BGs would still have been bouncing all over the land. Instead, my soft diet mostly consisted of these items which helped keep my BG spikes to a very small even keel. I COULD tolerate eggs--we are all different. My pouch is called Iron Will. 1. Flaky white fish (cooked in foil or softly pan sauteed in olive oil)--think tilapia, pangasius/basa, sole, haddock, John Dory, red mullet, haddock, pollock, cod, salmon 2. Canned salmon, tuna, chicken whizzed in a small mini chopper with Greek yogurt and a tiny bit of mayo/mustard and dill relish, s/p/gran garlic 3. Poached eggs/soft scrambled eggs (scrambled eggs that are cooked past 160 but are not set-up and rubbery) 4. Egg salad with cottage cheese 5. Cottage cheese with a dollop of greek yogurt and some peanut butter powder (low carb, low fat), and Walden Farms blueberry pancake syrup (zero cal, zero carb, zero fat) 6. Chili/soups made with slow cooked ground turkey and low glycemic veggies (no potatoes/root veggies/beans or legumes) 7. Veggies: Roasted smashed cauliflower (to replace mashed potatoes), frozen broccoli steamed until mushy then mushed with a wedge of Light Laughing Cow Cheese, green beans cooked with onion and chicken bouillon, sliced avocado, seeded and peeled tomato, frozen spinach cooked until mushy and then combined with a little Light Laughing Cow Cheese or low fat cream cheese or chevre Those were my foods for the "puree" phase until I was able to eat a normal diet at 4 weeks. My BGs were routinely in the 80s and low 90s after eating. They never spiked more than 10points after a meal from pre-prandial numbers. And my hunger was kept to a minimum. When I HAD to eat something I would drink fluids and that would help meet fluid intake and keep from snacking. I ate every 2-3 hours, just a tiny amount until my tummy could handle more. I had 6 meals a day spread about 3 hours apart. I supplemented with only 1 protein drink per day and got off of them as soon as I could--that's what my doc wanted. I still have 3oz of protein drink in coffee each day. Now I eat 3 meals + the protein coffee a day. If absolutely necessary to make a protein goal, I will add a snack in--or if it's a random Starvin' Marvin day. I do have those--usually right before a big losing phase. But they aren't every day. They are very random. Otherwise, I have little hunger and eat by my scheduled planned meals. Hope this helps. Your hunger is partly cuz your blood sugar and insulin is still crazy and cuz you then inject MORE insulin into your body. You're on the BG roller coaster from hell. The only way to break it is to reduce your bg/insulin response to meals and bring that into control. You can cut your insulin in half the second you decide to live that kind of life, then continue to reduce it until you're off of it. It may only take 2 weeks. Your hunger also comes from trying to transition from being a carb/sugar burner, to being a fat burner (which normally happens as a result of us going so low in calories (and often carbs)). Your hunger is ALSO coming from the types of food you are putting in your body (last night's meal) AND because you are not eating dense proteins yet. If you give it half a chance, this surgery will work for you and will help limit your food. But you are still in control of your choices of food. The surgery is only a mechanical limitation. You're smart and rationalize like nobody's beeswax. So if you want to figure out how to fu*k your new tool, you WILL succeed and either quit losing or regain to beyond starting weight. Then you'll really be fu*ked.

I have found that the key to eating eggs (for me) is to make sure that they are cooked soft or have some type of sauce on them. They must be moist in order for me to eat them. I mash up 2 hard boiled eggs with a bit of greek yogurt and it works very well.

A lot of great advice here but you have to do your part and make the decision to change TODAY---get rid of all the processed, refined crap you are eating. You do not need it, your dogs don't need it and it is so bad for you. You need lean protein, fresh or frozen vegetables and a liberal amount of healthy fat. I do not think pureeing the meats in a blender and adding broth and plain yogurt to make them doable would be wrong. Curious what you are drinking instead of water. Crystal Light and others are okay but juices and sodas are not. 64 ounces per day minimum and actually more is better. Make sure your protein shakes are low carb and IMHO smoothies loaded with bananas and berries are not appropriate. Commit to 7 days of no sugar, no fruit, no processed junk food and veggie carbs, protein and healthy fat only and you will feel less hungry. I would stop the insulin for now since being a bit high is much safer than low with Type II diabetes and continue to monitor. It will be rough for a few days but you can do it. All kinds of exercise on YouTube or tapes/discs that do not require leaving the house. Post on here several times a day for support and encouragement.

Late to the party, I feel the pain of being actually hungry (y'all have seen me say in so many times in sure). I'm 11 weeks post op, I've been hungry since practically coming home from the hospital. I've scanned through this thread, and I'm giving my 2 cents. After my liquid phase was over I decided to go gluten free, I don't do any bread or crackers or anything like that, gluten is an inflammatory substance and I have arthritis in my hands and knees from Lyme disease so no thanks. I'm not diabetic though. Anyway, I'm hungry A LOT. I've cut out most carbs, sugar and I've found (PS, I had a wicked sugar/carb addiction and being severely depressed doesn't help) I don't crave carbs or sugar anymore. I eat my meals, which are protein and vegetables I rarely eat fruit because of the carbs berries I do eat occasionally. I do not give in to the hunger, I have one snack (maybe) a day which is protein. I drink water or decaf unsweetened tea if I feel hungry between meals. I keep my calories under 1000, I just don't give in to that hunger beast. There are days I will sit with the cabinet open but then shut them. I have 2 teenagers and a stick of a husband and they all are adapting to no snacks, I also have 3 dogs that get dog bones. I keep a food journal and have the calorie king book my nutritionist have me. I will not eat bread or any sweets. I eat low-fat cheeses, I make my own Greek yogurt, honestly I'm sick of almonds. I've lost 53 pounds so far, I have to really start exercising, but you can do it. I lived off toast, crackers, coffee, peanut butter m&ms and cigarettes forever, oh and Coca-Cola. Use this tool and kick some ass!

Since you can drink OK, make sure everything you drink contains protein. I could barely eat more than a couple tablespoons at a time for several months, but I still got in 60-80g protein starting day five via protein shakes, milk, and even thinned Greek Yogurt. And no, I didn't want to eat, either, but I forced myself to get proper nutrition. After all, the whole point of surgery was to be healthy. Like @@perforce suggested, it's easier to eat a couple tablespoons several times/day than it is to try and eat just 1 meal.

That's wonderful you're doing so well weight loss wise! I don't know why eating would be a torture at almost three months out, so not sure what is happening to you other than you have to really start thinking about how to eat and planning your day out so you can eat enough and hit your food/water goals? Are you having specific issues like pain or difficulty swallowing or something? I was pretty much fine after the first month other than being sensitive to sugar (which was a good thing) and an intolerance for eggs until about 6 months out (just threw them up every time so stopped eating them until about 6 months out and it's good now). As time goes on, you will need to eat more, and you need to start eating real, whole foods. You need to be making your Protein and Water goals daily, and if you can't do it with the 3X daily meals, then you need to be adding in some snack times and getting in enough calories where your body isn't starving itself. You're still pretty early out, but at 600 calories daily, you're likely in a nutritional deficit that can't be healthy long term. Please do your best to start eating healthy Snacks (a cheese stick with a handful of almonds, a cup of low carb yogurt, some grapes and baby bel cheese wedges... ) There are tons of ideas on here and other bariatric recipe sites. Please discuss your difficulties and calorie intake with your doctor because this isn't healthy long term. And you will notice things like hair loss, exhaustion and muscle loss if you don't start eating a bit more and getting your protein and water in.

I had this problem too and during the clear liquid stage, the doctor had me taking liquid immodium. 5 days later, once I was on the 3 shakes a day, he has me having one activia light vanilla yogurt (70 calories) a day to regulate my stomach flora and I am fine now.

You are doing great TXdiva! Keep up the good work and let us know how your visit goes. Russ, I was still on low fat creamed Soups, sugar free pudding, yogurt, etc. during my 3rd week.

Today is Day 28 Post op. I pretty much feel back to normal. My energy has come back and I my incisions feel completely healed. I am supposed to be on clears still. I advanced my diet so I could make it through the long shifts at work. My nutritionist recommended this. I just started out with greek yogurt and refried beans. I also made an egg drop soup which was so delish. Good news!!! I finally found a protein shake I like, it's the Premier Protein Shake from Costco. Doesn't taste chalky to me at all. I have only tried the chocolate but will try vanilla next time I go. I am getting a little over 60gms of protein a day from the shakes and food. It is a huge relief since I was fearing dealing with a heart condition while being completely bald since I was having such a hard time getting shakes down. More good news, the scale finally moved. I am down to 225.8 which is a 24.2 lb loss since surgery. I haven't really been exercising since I had zero energy and had been sore. Now that I am feeling better I am going to look into getting a gym membership to hopefully get the weight loss going again. Overall, I feel more comfortable with my sleeved body. I do occasionally worry that any little twinge I feel near my stomach might be the start of a leak. I am not as apprehensive as I was initially though. I look in the mirror and see my face and body just can't believe how much it has changed at 24lbs. I can't even imagine what I will look like at 100 lbs down. I can't wait!