Observations About Weight Regain in the Absence of Easy Cues

I last wrote about my small but significant weight re-gain, and returning to tracking my eating. Although in March I wrote "see you in a month," it's been several months, so there's a decent amount of data on how things are going.

Tracking my eating has been very helpful. But despite that, I noticed I was eating more. I was increasingly concerned that I my little stomach may have stretched irrevocably: I was able to eat larger portions without experiencing the sensations that would cause me to immediately stop eating. 

For more than a year after the surgery, when I ate, I would very quickly feel full. If I ate one bite past that feeling, I was uncomfortable. Two bites, I would be overwhelmingly uncomfortable. Three bites was impossible, or I would run to the bathroom gagging. Thus I learned to be satisfied eating less!

I gradually lost this instant feedback, slowly enough that I didn't notice it on a daily basis. And then one day, I realized I was eating larger portions. In the summer we grill burgers on the deck. Last summer I would cut my burger on a bun in half, eat one half, and save the other half. This summer, I ate a whole burger with no discomfort. This worried and scared me. 

Then something interesting happened. I tried eating the post-surgery portion sizes and stopping, even though I wasn't getting that stop eating now! feeling. And I found I could stop, and was no longer hungry.

This may sound ridiculous or obvious, depending on your experience. But in my past experience, pre-surgery, I was almost always hungry. If I ate a smaller portion, I needed to cope with the feeling of still being hungry. That is very difficult to do on a consistent basis. 

The half-burger is one example. Another example is my mid-morning snack, between breakfast and lunch. I could eat x amount and not feel uncomfortable. Or I could eat half-x amount and also feel like I'd eaten enough.

So it turns out I can eat more -- but I can also eat less.

This causes me to wonder whether the disappearance of the immediate and non-negotiable feedback cues are the reason for some people's long-term weight regain after bariatric surgery. Because the big difference post-surgery is that immediate stop eating now sensation. Without those non-negotiable cues, I must be much more mindful of portion size and quantity. I must make very conscious choices of when to stop. This is a whole different post-surgery outlook. 

If you've never been overweight, or you're not someone with a big appetite who enjoys food, this may sound easy. I can tell you it is not easy. It is challenging. However, I can now do it -- where in the past, I could not.

So now in addition to tracking my food, I have to negotiate my portion size in advance of every meal. This means I can never let myself get too hungry. That's always been important for me, but now it's crucial, if I'm going to avoid re-gaining weight. 

Right now my weight is -37 from my pre-surgery weight, same as it was one year ago, and three pounds less than it was in March of this year. I'd like to lose a little more, but most importantly, I don't want to gain any more. 

A List of Good Things that Have Happened Since my Surgery

For the first time since making the decision to have bariatric surgery, I'm struggling. That in itself is pretty good. I decided in September 2019, so it's been nearly a year and a half with no significant issues. 

I can't and won't deny the issues I'm having right now, but a comment from my friend and blog reader "mkk" made me stop and take stock.

Up to now, any negatives I've experienced were physical, such as pain from eating too quickly, or nausea from eating too much, or the dreaded constipation. I expected things like this and -- although yucky while they are happening -- they're not a big deal.

The negatives I'm experiencing now are mental and emotional, and we all know those kinds of issues can be much more difficult and persistent. There are two issues.

• I am obsessing. Obsessing on calories, portions, weight.
• My appetite has hugely increased. This is very concerning to me, because if this whole process becomes an issue of willpower... it will not be sustainable. More about this in a future post. I'm not ready to talk about it yet.

Here are the positives that have taken place so far.

• I was terrified of the pre-op fasting, and it turned out to be fine. 
  
• I traveled to the surgery and back -- multiple flights and hotel stays -- with zero problems.
• My experience at the hospital in Mexico was excellent. 
• I traveled to the US and Mexico and back and did not get covid!
  
• Throughout my recovery, I was on paid work time, and working from home, so it was easy to work with the post-op eating plan and other self-care.
• A month before the surgery, I received a check in the mail -- out of the blue, totally unexpected -- that covered the full costs of the surgery! We ended up paying only for transportation, which was very manageable.
  
• My physical discomfort while recuperating was minimal.
  
• I've lost 39 pounds. This includes a sneak-peak at the scale in mid January. Without this surgery, losing almost 40 pounds was completely impossible.
• I'm comfortably wearing t-shirts that haven't fit me in 10 years.
  
• My low-back pain has returned to levels I experienced in the early 90s -- easily dealt with with a few stretches.
• My knees feel much better.
• An issue I was having with my bladder has disappeared. 
• My ankles and feet are no longer swollen -- a condition that was chronic.
• I am less self-conscious about my appearance in video-conference meetings (Zoom, Teams, Hangouts). This feels really nice.
  
• I'm still enjoying food! I was afraid that the surgery would rob me of this basic enjoyment, and that has not happened. This is wonderful.
• I'm still enjoying cooking, and my partner and I are eating mostly the same food.
  
• I'm able to eat almost anything in small quantities. I'm choosing not to eat unhealthy food, but if I wanted to have a small portion of something on my "avoid" list, I could. Having choices rather than being told what I can and cannot eat is important to me and much more sustainable.
  
• With my knees and back feeling better, I am already more physically active, and I'm feeling the rewards of that every day.
  
• And this is all without knowing the results of any bloodwork. I have my first post-op tests in early February.  

 Really great. 

The two issues I mentioned above are real, and they are troubling me. But they are not the whole story.

A Word About Poop, Plus Better Information From Canada

I've left out part of my recovery and adjustment story: information about bowel movements. That's what happens when you know friends and family are reading! It's a bit embarrassing to share my poop stories with them!

But as I always say, this blog is for myself -- and it's also for anyone else who is considering or has had bariatric surgery, who might stumble on it. I've already heard from some readers who are in that category.

So with that in mind, here is a word about poop! Obviously if you are free to skip this part.

The part about poop... in case you want to skip it

When I caught up with WRD after the surgery, she asked, How are your bowel movements? And I answered, "I haven't had any, because I've been on a liquid diet for so long," as if this was the most natural thing in the world. I can't remember what she said... we just moved on.

Two days later, I had very intense gas pains and cramping, the worst I've ever experienced. Only then did it occur to me that I hadn't had a bowel movement in three weeks! Probably not good, liquid diet or no. (A friend who is a medical professional, and who has had multiple surgeries, told me that anesthesia can have that effect as well.)

This pain went on for hours. I was nauseated, sweating, just absolutely in agony. I had Gas-X, which the hospital had told me keep on hand, both before and after surgery, but it didn't do very much.

I sent my partner to the drugstore for Senokot, as I know that's supposed to be a natural product and more gentle than something like Ex-Lax. 

I took some Senokot, then was exhausted from the pain and went to sleep... and woke up in the middle of the night, racing for the bathroom. It was disgusting, but I did feel much better afterwards.

I told WRD about this, and she asked if I was taking my Colace. Say what now? 

She said that on the checklist for bariatric surgery (meaning the information from the Canadian province where I live), it says I should be taking Colace, a stool softener, every day. We bought some at our local drugstore and I've been taking it since. It's also a gentle product, and can take several days to work.

Since then, I've had two bowel movements, but I would say I am still constipated. This is definitely on the list of potential side effects from the surgery, so I will continue to monitor it. Another bit of data to add to my food diary! 

The part about the information

This experience brought up something else, too: I was missing information. 

Before my surgery, WRD asked if I had the information booklet from our public health care. I thought I did... but what I actually had was a booklet for the orientation process. It was more general "what you can expect" information. 

The Colace incident made me realize I did, in fact, have the correct booklet. WRD sent me the full provincial booklet -- and it was so much better than what I had from the hospital! This does not surprise me. It makes sense that a public health program is going to be much more detailed and have better information than a private clinic. 

On the other hand, the dietitian that works for Oasis of Hope Bariatrics, where I had the surgery done, seems not to understand the concept of advance planning. Pre-surgery, I had to practically beg her for the diet plan. If it had turned out I needed to order Optifast, as I thought I did, I could not have bought it in time. 

Similarly, she would not give me the Phase 3 diet until the day I was ready to start that phase! She said she does this so patients won't start early. But what about planning and shopping in advance?! The day I was supposed to start taking post-surgical vitamins, she sent me a link to where I could purchase them! 

The information from our province had a checklist of everything you should buy in advance, including the vitamins, so everything is on hand when you get out of the hospital.

WRD gave me the full run-down on vitamins, and I purchased some locally while I wait for a shipment from my preferred online vitamin store. This meant I started the vitamins five days late. I'm sure I won't become malnourished in five days, but it was disappointing.

The provincial booklet is also better all around -- more detailed, written more clearly, and better designed (more accessible). Again, this does not surprise me, but I'm disappointed I didn't have this all along.

If you're in the US and you end up having weight-loss surgery done privately, you'll want to advocate for yourself with the clinic's dietitian, or if you're able, get in touch with a dietitian on your own. 

More About Phase 3 Eating

I had an excellent session with WRD yesterday, which really helped me understand the Phase 3 pureed food diet.

Two pieces about this phase seemed particularly challenging: the protein requirement and drinking enough water. And one instruction was confusing.

Protein

The hospital guidelines call for 60 grams of protein per day. That seemed like a high bar, but I was able to do it with a milk-based protein shake (protein from both milk and powder) plus small amounts of protein throughout the day, such as tuna or salmon salad. 

But... WRD told me that Health Canada says when you're recovering from this surgery, your requirements are much higher -- 70-120 grams per day. How on earth am I going to make that happen, at serving sizes of 3-5 tablespoons?

The answer -- as vegans and body-builders know -- is protein powder. I have unflavoured whey protein, and I can add it to almost anything. Depending on the food, it may change the texture slightly, acting like a thickener, but it doesn't change the flavour. This morning I pureed some low-sodium chicken-vegetable soup with a tablespoon of protein powder: 12 grams of protein. 

WRD recommends doing this for everything I eat. This can really increase the range of eating, too -- oatmeal, baby food fruit or vegetables, and soups can all be on my menu. Not at all once, of course, but over the course of the next couple of weeks. 

Water

The hospital instructions say I'm supposed to drink 2 litres (64 ounces) of water per day. I literally cannot do this. There aren't enough hours in the day to get both the protein requirements and drink that much water!

WRD thought 2 litres was excessive, especially considering I am also drinking a protein shake, V8, and soup. She feels that 1 litre (32 ounces) is adequate. I'll be able to do that without any trouble.

Pureed but higher-fat food

The hospital guidelines suggest hummus and smooth peanut butter as good go-to food for Phase 3. I enjoy both of those and would be happy to eat them (although I can't put them on a vegetable or cracker at this point). However, everything I read says to avoid high-fat food... so there's a contradiction there.

WRD recommended staying away from hummus and pb for another week, then trying in small quantities, and adding protein powder to the hummus. I've ordered some PB2 and look forward to trying it.

Vitamins!

Now is also the time to begin taking vitamins, which I will have to take for the rest of my life. Some people find this difficult or oppressive, but fortunately I have no problems with it. I already take several vitamins and supplements, adding a few more into the mix is no big deal.

The requirements are:

- A prenatal multi-vitamin that contains folic acid, zinc, magnesium, and iron

- Calcium citrate

- Vitamin B12

- A higher dose of Vitamin D (Everyone in Canada is supposed to take Vitamin D, and these guidelines double the recommended dose.)

 

I Can't Stand This Anymore: Moving On to Phase 3

I'm moving on to pureed foods, two days early.

According to the hospital, I'm due to advance to pureed food on Wednesday of this week. From everything I see online, these are approximate guidelines. I cannot stand the liquid diet one more day! It's not the liquid that's getting to me, it's the total lack of variety. I need to taste something other than protein shakes, V8, and plain yogurt. 

The pureed food phase is a bit complicated. In looking for more information, I've discovered an overwhelming number of bariatric recipe sites. Most are like all recipe sites -- loaded with ads, floating video ads, stealth marketing, and the same recipes over and over again.

There are also myriad people advertising their services to be your "bariatric coach". I'm hoping I already have that in the WRD (I've added Wonderful in front of Registered Dietitian), but if I need more support I'm not adverse to finding it online.

Regarding the pureed food phase, there's a lot of conflicting information on what you can and cannot eat. These recipes look yummy, but they contain small amounts of some high-fat ingredients like tahini and blue cheese. I thought those were off-limits.

Do not worry: I'll stick to foods that the hospital says are safe until I can speak with WRD for more clarification. So far this means:

* Pureed tuna, chicken, ground turkey, eggs, tofu, and whole grain hot cereal are all OK. That's plenty to get me started! 

* Serving sizes are 4-6 tablespoons -- and this is supposed to take 20-30 minutes to eat! This will be my single greatest challenge. I eat too fast, and I will have to teach myself how to slow down. Waaay down.

* Food is put in the food processor rather than the blender.

* I'll use a muffin tin to separate and store portions.

* There are some restrictions. At this phase, your stomach is not ready for red meat or for any bread products. And you're not supposed to waste calories on high-sugar food. 

* You're supposed to drink a lot of water between meals, but not with meals. I'm finding the water guidelines challenging.

Here goes! I'll report back soon.

Post-Op Week 2 Progress Report

Things seem to be progressing very well. 

My wound care has ended, so I no longer have to peel band-aids off my torso every day. That's a nice change.

I had been experiencing pain or discomfort in my upper abdomen -- exactly where the highest scope wound is -- when I would swallow liquids. (This is normal.) It's occurring less frequently and less severely. Yay.

I can now drink six ounces of most fluids without pain or discomfort, as long as I sip them slowly.

I'm finding more ways to make a plain protein shake taste better. I didn't buy artificially flavoured protein powder or pre-mixed protein shakes. I usually don't like the taste of any flavoured beverages, and they are always too sweet for me. The plain (unflavoured) protein powder in milk (or coconut milk) was fine with a cup of frozen fruit blended in, pre-surgery. But I can't have fruit yet, and the plain taste was pretty dismal. 

I thought of these ingredients to bring flavour to the mix without adding anything I can't yet eat. I'm using combinations of:
-- vanilla extract
-- cinnamon
-- cacao powder
-- mint leaves
Huge improvement! I'm all kinds of pleased with myself for thinking of this on my own.

The wonderful RD also told me about PB2, peanut protein with all the fat removed. I don't know why I had never heard of this before? Perhaps because I'm not vegan, so I'm not actively looking for protein sources. I don't know if I can get it in our town or if I have to order it, but it sounds like a good option.

I'm walking every day. Only a little so far, but it feels good to get outside. 

I get a daily email from the Government of Canada, asking me to confirm that I am still isolating, and declare whether or not I have symptoms of covid-19. I've also gotten a phone call from a public health worker, asking about my self-isolating plan and how it's going.  

This morning I am cooking another batch of dinners for my partner. He did the shopping and he washes the Instant Pot insert in between dishes I'm cooking. It's not making me hungry, although I do have to watch the impulse to taste things, or even lick a spoon. 

While I'm cooking, I'm making chicken broth for myself, then re-purposing the chicken in a dish for A. This will be much tastier than the pre-made broth. I don't buy canned soups because of the high sodium content, and the broths made for cooking are not very tasty by themselves.

Post-Op Diet: Final Day of Phase 1

Today's the final day of the Phase 1 diet, and good riddance. Although it will be quite a while until I eat solid food, I am looking forward to a tiny bit more variety, plus some protein.

Phase 2, which starts tomorrow, includes a protein shake -- milk (any kind) plus protein powder, no fruit yet -- consumed over the course of the day. You can also eat small portions of Greek yogurt, and thicker juices such as V8.

Phase 1 and 2 combined are two weeks. For Phase 3, you'll have to keep reading. Ha! I'm kidding, but I'm determined not to look too far ahead. One day at a time.

Yesterday I learned why you are advised to use 3-4 ounce portions! I poured a tiny extra bit of juice, such a small amount, it seemed harmless.. but ugh, it hurt going down. I didn't do it on purpose, but I will purposely avoid that now.

Other than that occasional discomfort, I feel fine! No complaints.

Post-Op Diet: Phase 1

For the first five days after surgery, you can have only clear liquids: water, coconut water, grape juice, apple juice, herbal tea, strained broth. (Gatorade-type drinks, flavoured water, and jello are also allowed, but I don't eat those.)

The key to this is taking small amounts, frequently. The guidelines are 3-4 ounces, sipped, not gulped, every hour. 

Today is Day 4. It's not bad. I already notice something that I know will be an ongoing adjustment. I open the fridge to get juice, and I see food -- and my head feels hungry, not my stomach. In other words, it's not actually hunger, it's a desire to eat. 

Your stomach "teaches" your brain: the hormones secreted by your stomach tell your brain that you're hungry. While this is happening, you look at food, think about what you want to eat, and your brain associates looking and thinking about food with hunger. Your brain learns that food makes you hungry. 

During Phase 1, 2, and 3 of the gastric sleeve diet, I'll be re-wiring that connection, listening to my stomach instead of my head.

Greetings from Self-Isolation

I'm home!

Because I was out of the country, the Government of Canada requires that I self-isolate for 14 days. This is a law, and it's enforceable -- they do check up -- but regardless of that, I take it quite seriously. The incidence of covid-19 in our area is very low, and the last thing I want to do is expose anyone to the virus.

Self-isolation is not a perfect system, as it was impossible for me to go directly from the airport to my home. I took extra precautions in that interim. Now that I'm home, A and I are sleeping in separate rooms, not touching, and distancing. I couldn't even hug him when he picked me up from the airport! 

A and I talked about it on the way home, and we both feel my chance of exposure was very low. 

- 100% of the time I was away, 100% of everyone around me was masked. Masks are mandatory in airports, on flights, and in the hospital.

- I practiced social distancing the entire time, with two exceptions -- the two crowded flights. And in those, the seat beside me was empty on both flights.

- I washed and sanitized my hands frequently.

- I was not in any restaurants, clubs, events, or even crowded stores.

Another thing -- and I don't know if or how this figures in -- is that I may have already had covid, in early March. While traveling for work, I became very sick, with all the symptoms. We don't know if I had it, and if I did, that doesn't mean I have immunity -- but it could.

I've been working at home, so even when I go back to work, isolating is not an issue. 

I'm counting the days, hoping I don't get sick.

Two Days Post Surgery: On My Way Home

This morning I had my last round of intravenous meds and a nurse removed the IV. The patient coordinator went over everything, and gave me a care package of instructions, medications, and supplies to clean the wound where the drain was. They also gave me copies of the bloodwork results, EKG, and all the medical info so it can go in my records back home.

I'm feeling OK and eager enjoy a week of rest and relaxation. 

A note about this blog. As I've mentioned, I'm writing this for myself and perhaps for anyone who might need this information from a firsthand source. Friends and family are very welcome to continue reading, but please feel no obligation, and not the slightest need to apologize if you want to stop reading. Deal?

A Big Improvement in a Short Period of Time

It's still the first day after the surgery, and I feel better and better as the day progresses. The doctor removed the drain -- ouch!! -- and soon the IV will come out and I can take a shower.

The hives are acting up, so they're letting me take my antihistamines now. 

This morning I thought, how am I going to travel on Thursday? But I already see that it's possible, and won't be so bad. I have to be super careful not to lift my suitcase, and to ask other people to lift it for me. And I have to walk slowly. If I do those two things, I'll be fine.

I wish I could go all the way home on Thursday! But alas, I can only get as far as Vancouver, then will fly to Port Hardy the following morning. Then I have an entire glorious week off work. Can't wait.

 

Recovery Day One: Time To Break Out an Old-School Cliche

Well, it's done! This morning I am thinking of that very old poster cliche, Today is the first day of the rest of your life. I've made this permanent change, and it feels daunting, but I will continue to take it step by step.

Monday night I was prepped for surgery, including an IV line for hydration and follow-up medication. Then yesterday I had visits from a whole slew of medical staff: the surgeon, the anesthesiologist, the doctor who coordinates my care, the patient coordinator who I've been emailing with, and a nurse. The dietitian even came by to say hi and tell me we will speak tomorrow.

They gave me a chest x-ray, an EKG (normal! whew!), compression stockings, and maybe some other things I've forgotten. 

Then I was wheeled off, needle, drowsiness... then I was in my room. Ta-da!

I woke up feeling like I'd done 1,000 crunches, with pain under my ribs. Apparently laparoscopic  surgery pumps you full of gas. Ouch. 

Once I woke up more fully, the doctor visited again, saying the surgery was fast (45 minutes) and easy. He told me to walk around as much as possible, as this will help the gas dissipate. Also, I have a drain (TMI?) that they will monitor, plus a breathing thingy to help facilitate deep respiration... also for gas.

So I spent the rest of the day alternating between sleeping, walking around the room and in the hallway, and having nursing staff come in and out putting various medications in my IV line -- anti-nausea, antibiotics, anti-gas, painkillers -- and giving me ice chips.

IV lines! Why wasn't this always standard?! When I was 12 years old, I had knee surgery. All painkillers and antibiotics were given by injection into my thigh. Always the same thigh. After a while, it hurt so much that I was crying, and preferred the surgical pain to the constant stabbing. It also caused nerve damage; the area was numb for nearly 20 years! Why didn't they use an intravenous line? One needle, and you're done.

I can tell that the standard of care here is very high. The staff is very methodical and deliberate, with great attention to detail. Perhaps this is a function of working in a private clinic without a huge number of patients? I don't know. But my experience in hospitals, either for myself, my partner, or anyone I've ever visited, has been that staff are very rushed, and if you don't advocate for care, it's easy to be overlooked. (Admittedly my experience is limited to New York City, where everything is always over-crowded and rushed, and the same, but slightly less, in suburban Mississauga.)

You may be wondering about a language barrier. The doctors all speak perfect English and are obviously fully bilingual. The people who seem to be the head nursing staff speak a lot of English; they also use translation apps on their phones, for both you and them to speak in. The aides don't have much English, but instead get someone for you who does. 

Everyone is friendly and so caring. It's like this in BC, too -- medical staff are unfailingly friendly and caring. I did not find this in NYC or Mississauga! I'm guessing, again, that's it's down to workload. It's hard to demonstrate caring when you're constantly rushed off your feet. 

So it's morning now. Today will be full of breathing tests, walking, drains, and other recovery business. The doc told me there are three different tests for leaks. If any are found, it's back to surgery to repair them. However, he informed me, his work never leaks. The hospital's complication rate is less than 1%, and his is zero. (Surgeons!)

To be honest, I don't know how I will be ready to travel tomorrow afternoon, but then again, that is more than 24 hours away. I already feel better this morning than I did yesterday.

One weird thing: I had an allergic reaction to one of the medications. My face and lips got swollen and puffy. No respiratory issues -- my breathing was not affected, only my face. My lips look like I tried to give myself silicone injections and didn't read the instructions. They gave me antihistamines, and will change both the nausea meds and the painkillers.