Once the weight loss surgery is completed, how do you truly maximize its success?  What are the critical secrets to losing weight effectively and in the most healthy way possible?  How can you not only lose pounds, but also feel better and have more energy?

These are some of the most important questions that are answered in my newly released e-book called, “After weight-loss surgery”.

I have had the great privilege and the unique position of serving as the Medical Director for both a nationally recognized surgical weight loss center, as well as an acclaimed medical (nonsurgical) weight loss surgery, iMetabolic or the International Metabolic Institute.  From these positions, I have had the great privilege of helping thousands of people successfully lose weight using all of the proven techniques available from every discipline.  It has given me some great insight into what truly works to successfully lose the weight and keep it off.  Some of the critical factors that are described in detail in “After weight-loss surgery” include:

• How to adopt the life changing attitude necessary for successful weight loss.

• What to do if your weight loss stalls or you  hit a plateau.

• How to avoid weight regain and what to do about it if you experience rebound weight gain.

• Every thing you must know about vitamins, minerals and nutrients after your weight loss surgery.

Each of these topics is covered based on experience from real people and also from the very latest in clinical scientific publications in the field of weight loss and weight loss surgery.  I highly recommend this publication for anyone who has had weight loss surgery or is about to have it to help serve as a blueprint for your future success.

For many years, the kind of protein powder shake mix that one could find was meant for muscle building in the gyms.  These shake mixes often had names that implied bulk and strength and growth and they were not only high in protein but were also very high in calories generally. So for a body builder or a young football player or wrestler aiming to bulk up, these shake mixes were just the ticket.

Today, more and more people are going to gyms for different reasons.  Yes, they  need to increase muscle, almost all of us do.  But increasingly, most people are also needing to burn fat and lose weight.

So the protein shake mixes must be different.  Instead of something aimed at helping a young person build muscle and build weight, this more modern shake mix must help a person build muscle while reducing weight.  So how does one do this?

The key is in the ingredients of the shake mix, as well as in the exercise performed by the person using it.  Sometimes young athletes are able to devote several hours a day toward pumping iron and building muscle. Very few adults can do that, simply because of time.  In addition, a  young athlete has typically a much higher basal metabolic rate than does the average person who needs to lose some pounds.  So the ingredients much match the person.

The ideal shake mix has now changed and takes into consideration all these factors.  One that now consists predominantly of proteins with the right amino acid mix, adds vitamins that are helpful both for muscle building and weight loss, and lastly contains low total amount of calories, serves to accomplish all the goals.  In this way, a person can benefit greatly from both the protein shakes and from their exercise regimen.  I highly recommend the protein shake mix from iMetabolic that accomplishes all of these goals with some great flavors.  Please let the creators of iMetabolic know what flavors you  might prefer or what tastes you do and don’t like about their shake mix.

Technological products of all kinds seem to change rapidly. The makers of medical devices also know that in order to remain competitive, they need to continue to innovate. So we see changes in all kinds of medical devices year after year and these are almost always for the better.

I recently began working with the new REALIZE bands. The new innovations really have more to do with the surgeon than the patient. But they do represent improvements and make the band easier to work with, improve its handling, and add a couple of small features that have to do with the ergonomics for lack of a better term when the surgeon is working with it.

The new features involve a type of pre-curve in the band structure itself. This is a feature that has been present with the Lap-Band for many years. What this means is that instead of resting flat if you set it on the table, it assumes a curved shape with the curve bending inward toward the balloon side. It is a subtle feature, but it does help the surgeon with placing the band because the band “wants” to assume that curved shape already and it takes less coaxing and manipulation by the surgeon in order to place it in the proper position. Similarly, the new locking or clasping mechanism of the band allows a bit easier placement by the surgeon. It does appear the fill volume may change somewhat and I will report more on this as we gain more experience with it.

I continue to use both the Lap-Band and the REALIZE band, as does our group. Both bands appear to work quite nicely. They are both I think very well designed and easy for the surgeon to place. As far as I can tell so far from an anecdotal experience, there has not been any striking feature that has stood out among patients, doctors or providers that distinguishes the bands. At some point down the road we will report on longer term results, weight loss results and other findings, but having worked with hundreds of each band, there is not a strong feature that stands out or that patients have remarked upon distinguishing the two.

These small but incremental positive improvements or steps in improved design change continue the evolution towards better and better bands.

We have improved the flavors of several of the iMetabolic protein meal replacements. I cannot say enough in praise of all of our taste testers and all of the valuable feedback we have received from so many people. Thank you very much for tasting and enjoying the product and putting your thoughts down for us.

I have had a number of people who have found that the vanilla bean flavor and the chocolate are certainly enjoyable enough as is, but at times can become extremely delicious with the addition of a little bit of soy milk. I guess the key is here to be creative and enjoy the protein meal replacements while not diverging from your weight loss plan. So it just means examining how many calories and how many grams of carbohydrates you may be adding to your shake and as long as you stay mindful of that, I see nothing wrong with using some different additions like soy milk.

Of course, that’s really the whole concept behind the “Shaking it Up” book that was created by Chef Dave Fouts and Vickie Bovie the outstanding Registered Dietitian. It utilizes even more flavors and more ingredients to make the shakes what they are.

Times are tough.  A lot of people right now are facing difficult economic circumstances, jobs are scarce, and extra money is not just lying around these days.

With all that’s going on, how can a person manage to focus on losing weight?  The truth is that becoming healthier and skinnier can be economically very beneficial to a person.  However, to focus on weight loss requires some psychological clarity and focus.  It can be difficult when life has become very stressful for economic or other reasons to focus clearly on a goal of changing your life, losing weight and becoming healthier. But it is possible and it may be the best thing you can do to move forward in this area of your life even while  other aspects of life face great challenges due to the economy.

Losing weight and living at a healthier weight can save money for a number of reasons.  First of all, you simply eat less.  If you become disciplined and start cutting out a lot of the high calorie snacks and treats, this not only  helps weight loss but it helps with the pocketbook.  Yummy mochas and cappuccinos, not to mention ice cream and popcorn, are expensive and add unneeded pounds to the waistline. Becoming focused on a weight loss program allows you to save this money.

More importantly, however, if you can lose 10% of your excess body weight that translates into significant health improvements so much so that many people find that they are able to decrease or quit medications they are currently taking for problems like gastroesophageal reflux, painful bones and joints, and even diabetes and high blood pressure. With more significant weight loss, lots of medications and doctors’ visits fall by the wayside.

There are expenses with good weight loss programs. These include reading material, literature, audio programs, protein meal replacement shakes, low carb, low glycemic index snacks and meals, and even medications.  Yet, usually these are cheaper in the long run than eating regular meals.  Sometimes though cheap high calorie food can seem more appealing.

The bottom line is that you and your health are too important to do anything other than focus on losing weight and becoming healthier.

We have all tried to lose weight. We’ve all thought about it as a vaguely good idea and we have all wanted to lose a few extra pounds here and there. Some of us have tried several times to lose a lot of weight. But for only a small number of people is a clear game plan really ever established that allows them to set out on a course that will result in significant long-term sustained weight loss.

So how do you establish such a game plan?

Well, it’s more than just the idea that you’d like to lose weight, although that is clearly an important critical starting ingredient. It’s more than taking a weight loss medication or signing up with a doctor or even planning to have weight loss surgery. It is first and foremost a commitment to really see it through and enjoy the benefits of the long-term weight loss. Those benefits mean improved health for you for a lifetime. They mean a better quality of life, more fun with your family and friends, better success at work. In short, they mean a longer and healthier life. Who wouldn’t want that?

But achieving that goal requires going through many, many small steps, just like any major long-term project requires going through many small steps. Think of building a very complex and large model airplane. Think of the many, many, many parts and the intricate steps involved and the many directions. No one would think they could build a model airplane in a single afternoon. In fact, someone with experience building other model airplanes, or completing other projects, knows that to achieve this goal it is going to take a lot of time and effort and dedication and fulfilling many steps along the way. But don’t be deterred just because there are many steps or because it’s a challenging project. Nothing is more rewarding than achieving a goal like this one.

So how do you start? You start by identifying your goal and spending a good deal of time understanding the goal, why you want it, what it means to you and what things you will be able to enjoy, achieve, accomplish if you can succeed in this one goal. Your next step is to focus on the how. How do I get there? What are the steps from here to there? How do I achieve long-term lasting weight loss success? And to identify the steps involved and the how, you need to do a bit of research. I recommend reading every good source of reliable scientifically based information including books, pamphlets and CDs about the health effects of weight gain, obesity, about the methods of successful weight loss, and about the steps you need to take to lose weight and keep it off. I specifically recommend listening to the audio programs available at www.AudioDiets.com and reading any of the Special Weight Loss Reports that apply specifically to you, available at www.iMetabolic.com . Additionally, if you are considering weight loss surgery, please read Outpatient Weight Loss Surgery: Safe and Effective Weight Loss with Modern Bariatric Surgery that 360 Publishing is releasing in February of 2009. It has many other resources to guide you after you have finished it.

Lastly and perhaps most importantly, you need to make a commitment to take the steps necessary. You need to make a commitment to yourself most of all, but also to others who can help and support you along the way.

And then it’s time to start, to really begin. Because once you’ve established this game plan, identified your goals and committed yourselves to achieving them, nothing can stop you. In other sections, other posts, other articles and books, I talk in more detail about how goal setting can help you a great deal and about the specific steps you should take depending on your own personal situation to lose weight, and about commitments and where to begin.

I wish you great success in your weight loss journey. Tell us here how you began and what had worked for you.

Adjusting the taste for new meal replacements, our staff at iMetabolic continued to tinker with the taste of the new shake meal replacement powders until we felt it was perfect. So far between our world class chef (Dave Fouts) and our world class tasters (well, I’m not sure we are all world class tasters, but we like to think of ourselves that way) we have achieved a consensus on the fantastic taste of the vanilla, the chocolate, strawberry, banana and the orange flavored shake mixes. These meal replacements promise to be the best tasting, and the best quality protein shakes and meal replacements on the market today.

So stay tuned and get ready to try out the best tasting bariatric meal replacement mix around.

We always lament the increasing amount of “screen time” that adults, and especially children, are getting these days. One of the real pushes from the Obesity Prevention Foundation is to limit screen time for youngsters to no more than an hour a day. It is believed that too much screen time (whether it’s television or computer screen, video game or handheld gaming device) means just that many more hours that are not spent being active outdoors getting exercise. And because the TV shows, movies, computer games and internet options are so much more interesting and entertaining, we seem to be losing the battle with kids spending more time in front of the screen and less time outdoors using their muscles.

But one exciting and positive development is the Wii Fit and some other games and entertainment systems either on the drawing board or filtering out into the marketplace. These entertainment systems involve physical activity, monitoring, scoring and advancing through levels of physical accomplishments, even yoga poses. And so far, adults and kids seem to find the Wii Fit pretty darn entertaining. It offers levels of challenge, levels of accomplishments, exciting awards when reaching levels.

Have you tried WiiFit or other active games? What do you think?

I recently saw a patient in my office who I’ll call Cindy. Cindy is considering weight loss surgery as a young adult. She is 21 years old and has been struggling with being seriously overweight ever since she was about eight years old. She had worked very hard at staying as trim as best as she can, but at age 21 and at 5’4”, she weighs right around 205 pounds and struggles mightily to ever get below 200.

Cindy is very active. She works out three times a week. She participates in dance and swimming and she describes herself as a real “go-getter” at work. She reports that her friends are amazed that she is as overweight as she is given how active she is. Cindy is very concerned about her genetic tendencies for weight gain and poor health. Her own mother has almost become almost completely sedentary and weighs close to 300 pounds. Many family members have early heart disease and diabetes, and Cindy just does not want to go there. Cindy has made the decision to address her weight loss issue through bariatric surgery and has been considering what surgery to pursue.

For someone in Cindy’s shoes, it can be a tough choice. On the one hand, she is quite young, and as I have counseled her, it is an advantage to do something that is potentially reversible for someone who is so young. Since nobody knows what kind of good weight loss options will be available in 20 or 30 years, it makes a lot of sense for a young person to keep those options open. One of the underlying truths of medicine and surgery and science is that the pace of change and innovation continues to accelerate. So just in the last few years we have seen FDA approval of a number of new devices and techniques including the Lap-Band, the REALIZE, Stomaphyx, and many others are on the way. Imagine in 20 or 30 years what kind of new innovations may be possible. (My own hope is that we have a highly effective safe and durable weight loss medicine or appetite suppressant that finally works well without side effects!) So for a young person, one of the first considerations should be to consider not avoiding some of the irreversible procedures such as gastrectomy, biliopancreatic diversion, and to some degree, Roux-en-Y gastric bypass.

The Roux-en-Y gastric bypass, on the other hand, is extremely effective in preventing and resolving diabetes, a condition that runs in Cindy’s family. And while it is technically “reversible”, the surgery that would be required to reverse it would be fairly invasive, fairly major and may very well require open incision or scar.

So is there one simple single right answer for choice of weight loss surgery in young adults? No, I do not believe there is. I do think it requires weighing all of the considerations (which are discussed in other blogs, as well as in the book, Outpatient Weight Loss Surgery, Safe and Effective Weight Loss With Modern Bariatric Surgery.

Nutritional and Vitamin deficiencies following bariatric surgery.

While we are all thinking of finding some healthy holiday meals, and enjoying some excellent holiday recipes, let’s not forget our important vitamins!

Modern weight loss surgery is a highly successful intervention by almost any measure. In numerous studies modern weight loss surgery is demonstrated to prolong life, improve quality of life, and reduce the incidence and impact of many health conditions including diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, degenerative joint disease and many others. But weight loss surgery can lead to vitamin and nutritional deficiencies in some cases. These deficiencies can be serious, so it’s important for patients to prevent them by remembering to take the vitamin supplements your bariatric surgeon recommends!

Some overweight individuals have preoperative vitamin and nutritional deficiencies before they ever even attend a weight loss seminar. After bariatric surgery, the most common deficiencies occur in the operations which have a “malabsorptive” component, in which some of the intestine is bypassed, and some of the nutrients are not absorbed. In some intestinal bypasses performed prior to the 1970s, numerous nutritional deficiencies occurred that in some cases led to liver failure and hurt the reputation of weight loss surgery (despite the deficiencies, however, patients who had jejunoileal bypass markedly outlived their obese counterparts who did not undergo weight loss surgery).

Today, the frequency and severity of vitamin deficiencies is least after LapBand surgery (which usually requires only the Omni Bariatric Vitamin supplement), then increases with Gastric Bypass (which requires the vitamin supplements listed in the table below), followed by further increases with Biliopancreatic diversion or long limb gastric bypass (even more nutritional/vitamin supplements needed – email us for a list). In the vast majority of cases, vitamin deficiencies can be prevented by taking the vitamin supplements your bariatric surgeon recommends. iMeatbolic makes all of these supplements, made in FDA-inspected labs, available on their website at www.imetabolic.com.

VITAMIN SUPPLEMENTS NEEDED AFTER GASTRIC BYPASS

Iron

Iron deficiency anemia is among the most common nutritional abnormalities. Many female preoperative have iron deficiency, as high as 44% of patients in recent studies, including one in the Journal of Gastrointestinal Surgery. After Roux-en-Y gastric bypass surgery, as many as 75% of patients exhibit iron deficiency anemia if iron is not supplemented and the condition not treated.

Gastric bypass leads to iron deficiency anemia in large part because the bypassing of the acid-producing portion of the stomach prevents the reduction of iron to the absorbable ferrous iron. If you are experiencing symptoms such as fatigue or discomfort or enlargement of the tongue, these could be signs of significant iron deficiency anemia. Sometimes people with iron deficiency also feel cold even when the room temperature is normal. The problem is detected with a routine blood test, hemoglobin and serum iron studies (iron level, TIBC, ferritin, transferrin)

Iron deficiency is common enough that iron supplementation is recommended for every patient undergoing weight loss surgery. We generally use ferrous sulfate, 325 mg p.o. daily or this can be increased to twice a day. For more severe cases, intravenous iron infusion may be required.

Vitamin B12

B12 (cyanocobalamin) deficiency is common following bariatric surgery, especially Roux-en-Y gastric bypass surgery. The decreased exposure to stomach acid and the less overall secretion of stomach acid leads to less release and absorbtion of vitamin B12 from foods. Oftentimes, patients consume less B12 because foods such as beef and chicken are consumed less frequently.

Sometimes people who are deficient in B12 may also experience tingling or numbness in their hands and feet, or unsteady walking. Sometimes people experience an enlarged tongue, weakness or depression. Because B12 deficiency would occur commonly after gastric bypass surgery, it is a standard recommended supplement postoperatively. This is given either as an intramuscular injection monthly with 1000 to 3000 mcg per injection. Intramuscular injections are available locally at iMetabolic, at 971 W. Moana at Lakeside. More recently, good absorption of B12 occurs with sublingual preparation and nasal sprays. Our standard practice is for every patient to take sublingual B12 daily for a lifetime. Sublingual B12, and all of the vitamins we recommend, are available at our website and soon at the WBI Arlington office itself, after the renovations are done!

Thiamine

Thiamine is otherwise known as vitamin B1. Thiamine is found in foods such as beef and pork and to a lesser extent in some legumes, dried beans, peas and in certain grains. Mild thiamine deficiency is fairly common among seriously overweight individuals prior to surgery and can worsen after surgery or any prolonged illness with vomiting. The symptoms of thiamine deficiency can be vague and include fatigue, poor memory, appetite suppression, abdominal discomfort, difficulties with balance or unsteady walking, even confusion or neurologic changes. It is supplemented in the bariatric multivitamins an can be further supplemented if necessary in rare cases.

Vitamin B6 (pyridoxine)

Vitamin B6 is present in meats, beans, whole grains and certain nuts. Many people are deficient in B6 if it is tested rigorously. The incidence is probably increased after gastric bypass and bariatric surgery. It appears to be well absorbed and effective if given in a standard multivitamin dose. There are symptoms such as those of thiamine and B12.

Folic acid

Folic acid is important for red blood cell production. It is present in green leafy vegetables, as well as beans. Folate is another B complex vitamin that is absorbed less after gastric bypass surgery or any procedures that decreases the stomach acids’ contact with the meal. Confusion, weakness, anemia, enlarged tongue and neuropathy are all symptoms of thiamine(?) deficiency. It is treated with thiamine replacement and is generally bioavailable in the multivitamin. It can also be given as an intravenous supplementation.

Calcium and vitamin D

Mineral calcium and vitamin D are interrelated as they work together in maintaining the serum calcium levels. Vitamin D is found in milk, eggs, fish and liver. Calcium is present in dairy products. Calcium deficiency may result after gastric bypass and Vitamin D deficiency may result from any type of intestinal bypass procedure that leads to decreased absorption of fat-soluble vitamins. Fat-soluble vitamins (A, D, E and K) tend to be reduced most in biliopancreatic diversion, duodenal switch, and jejunoileal bypass. The fat-soluble vitamins can also become deficient in patients taking Alli or Xenical, the fat-blocking weight loss drug. The active form of vitamin D requires sun exposure to the skin.

Deficiencies of calcium and vitamin D lead to increased breakdown of bone deposits to liberate calcium for the bloodstream. Symptoms of vitamin D and calcium deficiency are muscle aches, fatigue, joint pain. Progression to osteoporosis increases risk of bone fracture.

Calcium and vitamin D should both be supplemented with1200 mg of calcium and 8 mcg of vitamin D or more. Some bone loss appears to occur with significant weight reduction independent of calcium and vitamin D deficiency.

Vitamin A

Vitamin A is a fat-soluble vitamin present in an array of foods including dairy products, pumpkins, cantaloupe and liver. Deficiencies of vitamin A can lead to night blindness and ocular symptoms. Deficiencies of vitamin A generally occur as a result of the deficiencies that involve the fat-soluble vitamins. This generally results from an intestinal bypass procedure such as jejunoileal bypass (no longer performed) or biliopancreatic diversion/duodenal switch procedures. In these procedures, fat absorption is markedly impaired. There is the potential for vitamin A deficiency with use of Xenical or Alli weight loss medications.

Treatment can be given with oral or intramuscular vitamin A. Specific oral vitamin A routine supplementation is not generally felt to be necessary after Lap Band or gastric bypass, but is necessary after duodenal switch or biliopancreatic diversion.

Vitamin K

Vitamin K is a fat-soluble vitamin present in green leafy vegetables. Deficiencies can lead to impairment of the blood clotting system and therefore lead to bruising and bleeding of the gums. Vitamin K deficiency is possible after procedures that result in significant fat malabsorption such as biliopancreatic diversion or duodenal switch and jejunoileal bypass. It appears to be less common and reported and is not routinely supplemented or tested.

Vitamin E

Vitamin E is found in green leafy vegetables, nuts, seeds and vegetable oils. Vitamin E deficiency appears rare and is associated with neurologic symptoms. It is not routinely tested or supplemented.

Protein deficiency and muscle wasting

Protein is increasingly recognized as import for maintaining muscles and for helping with weight loss. Bariatric centers generally recommend a person consume between 60 and 100 grams of protein daily.

Protein deficiency is often detected by serum protein measures including total protein, albumin and prealbumin. Protein deficiency can occur in patients who have complications following bariatric surgery or if they experience excessive food intolerance and diminished protein intake. Usually this problem is resolved once the person has begun eating more foods.

For patients with routine postoperative courses, emphasis on protein supplementation with meal replacements, shakes, bars and carefully selected foods are important to emphasize. A wide variety of protein-based shakes and snacks and other delicacies are now produced by high quality labs and manufacturers. We have made many of these available online at our website and at iMetabolic. Let us know online which ones you like or what others you would like to see carried!

It is also important to emphasize muscular activity to stimulate synthesis of muscle mass and preservation of lean body mass during rapid and profound weight loss.

Zinc

Zinc is a mineral found in meat, fish, eggs, grains and nuts. Zinc deficiency may be present in 5 to 10% of patients prior to surgery and zinc deficiencies result from procedures involving malabsorption, including gastric bypass surgery. Zinc deficiency is associated with hair loss, skin rashes and impaired wound healing. It is recommended to routinely supplement postoperatively with zinc in the form of a multivitamin that contains zinc. For specific identified deficiencies, increased dose of zinc sulfate may be warranted and may arrest hair loss following gastric bypass surgery.

Selenium

Selenium is a mineral that is an antioxidant like vitamin E. Selenium deficiency has been reported in a small percentage, perhaps 5%, of obese patients prior to bariatric surgery. After bariatric surgery, selenium deficiency increases although it is not clear what symptoms may arise as a result of impaired antioxidant function. Selenium supplementation is recommended as part of a multivitamin.

Conclusion

So enjoy the holidays, work hard to avoid the carbohydrates in all the holiday treats. Remember your weight loss and health goals. At Holiday events, try to enjoy the people more, and the food less! It sometimes takes hard work to achieve your potential, but you can do it.

And don’t forget your vitamins!