The Morbid Me

Protein and Water: Our Best Friends

Protein

Your Protein intake has to be 50% of your daily food intake. The most nutrient rich sources of animal protein are fish, poultry and meat. Dairy protein, including eggs, is another excellent source you can play with on a daily basis. Nuts and legumes are also good and you can use them as little snacks.

A protein rich diet will promote weight loss and increase energy. The body contains a variety of active proteins all made out of the same building blocks: amino acids. Amino acids are made of carbon, hydrogen, oxygen and nitrogen as well as sulfur, phosphorus and iron. Many diseases, including obesity, indicate an amino acid deficiency.

As a WLS patient, we have to eat lean protein or we will get sick, anemic, and weary. Weight loss will cease if we eat processed carbohydrates instead of lean protein. Dumping may also result if patients do not eat lean protein for the first half of every meal. So the basic rule is “Protein First”.

There is a difference between high fat proteins and lean proteins. A gastric bypass patient can’t tolerate high fat proteins such as bacon, fatty beef or sausage products or greasy fried chicken: these foods may cause nausea and vomiting. In addition, these high fat protein rich items contribute to obesity and should be avoided by anyone wishing to control their weight.

Water

We Gastric bypass patients don’t have a choice: we must drink lots water. Other beverages including coffee, tea, milk, soft drinks and alcohol should be avoided. Water is one of the most important nutrients the body needs to stay healthy, and energetic. A tell-tell sign of a gastric bypass patient is the ever-present water bottle.

The brain is more than 75% made of water; and 80%of blood is water. In fact, water plays a critical role in every system of the human body. Water regulates body temperature, removes wastes, carries nutrients and oxygen to the cells, cushions the joints, prevents constipation, flushes toxins from the kidneys and liver and dissolves vitamins, minerals and other nutrients for the body’s use.

Nutritionists say a precise measure of the body’s need for water is to divide body weight (pounds) in half and drink that many ounces every day. That number could well exceed 200 ounces a day for morbidly obese people actively engaged in weight loss.

The body will panic if actual water intake is significantly less than required. Blood cannot flow, waste processes are disrupted and the electrolytes become imbalanced. Proper hydration prevents inflammation, promotes osmosis and moistens lung surfaces for gas diffusion. It helps the body regulate temperature, irrigate the cells and organs and promotes all functions of elimination.

Certainly by drinking plenty of water many people could resolve inflammation and elimination problems that result from insufficient water intake. Adequate water facilitates weight loss. As a WLS patient, drink at least 2.5 liters of water each day.

“Gastric Pacemaker” may fool our Stomach

The company that invented the heart pacemaker is employing the same technology to trick obese patients into thinking their stomachs are full.

There is a lot of investment out there to get a piece of the us$100 billion obesity market. (The market for the severely obese is $5 billion to $10 billion.)

Medtronic Inc., the world's biggest maker of medical devices is trying to develop a battery-powered gastric pacemaker that causes the stomach to contract, sending signals of satiety to the appetite center in the brain, a small start-up also is working with the famed Mayo Clinic on a device that uses electricity to paralyze the stomach, reducing or stopping contractions that churn food as part of the digestion process.

Despite failures so far of some devices in clinical trials, companies are pushing ahead, convinced that medical devices hold the key to battling obesity. In the past, it’s implantable gastric stimulator, or IGS, failed to prove effective in a clinical trial in achieving excess weight loss after 12 months.

The device is implanted under the skin of the abdomen with electric wires placed on the wall of the stomach. It then "paces" the stomach by delivering small electrical currents that cause the stomach to contract.

Medtronic would also look at its deep brain stimulation technology -- which uses tiny electrodes implanted in specific areas of the brain to affect behavior, movement and other functions -- as a possible treatment for obesity.

Brain stimulation technology is currently approved in the United States to treat movement disorders such as Parkinson's disease and is being studied to treat obsessive compulsive disorder and severe depression.

Another company, Enteromedics Inc. is working with the Mayo Clinic on its own implantable device to fight obesity. But rather than stimulating the stomach like Medtronic's IGS device, its solution is trying to inhibit nerve function by using electrical currents to block the Vagus Nerve, one of five cranial nerves.

The device, called Maestro, is also inserted beneath the skin of the abdomen, with connecting electrical leads placed on the stomach. The electrical pulses block the Vagus Nerve and paralyze the stomach, stopping contractions that churn food as part of the digestion process. The way the device is used is still evolving.

The goal is to slow digestion so that the patient feels sated longer. The device also shuts down the pancreas and the secretions of digestive enzymes. The process effectively causes the patient to absorb less food, and thus calories, just like in gastric bypass surgery.

The future of treating obesity may lie in devices, but today there is not enough data.

Will my Insurance pay for my Surgery?

I have only heard bad experiences with this topic. Insurance companies just don’t understand the cost on the long term of having to deal with a morbid obese customer. In my particular case, I had diabetes, sleep apnea, hypertension, and you name it, all obesity related illnesses.

Just like in current politics, my Health Insurance (NHP in South Florida) made a preemptive strike a few years ago, by sending me letters informing their customer base that they would never pay for WLS. This way before I even considered the operation. So, from the beginning I knew it would be hard to deal with.

I tried a few letters back and forth, but at the end, and based on the feedback I was getting from other NHP members, it was a fight not worth fighting. So I decided to open my own pocket.

A few months ago I was presented the ebook called “Weight Loss Surgery Insurance Secrets” written by Craig Thompson. I read it and found it overwhelming interesting and informative on how I could (have) fought my way so my insurance company could pick up the tab. But it was to late for me.

I have been asked too many times about insurance companies and their WLS policies… So my advice is, get Craig’s Book, and continue to read ahead:

Insurance Companies exist because of the money, not your health

Insurance coverage for the Gastric Bypass procedure depends on a determination by your primary care physician, surgeon or specialist that gastric bypass surgery is medically necessary to reduce significant medical risks to your life. In general, your insurance carrier will also require (among other specific documentation):

• A thorough medical history
• A detailed diet history over the past two consecutive years under medical supervision
• Current height, weight and BMI (body mass index)
• A list of all co-morbidities that are or may be caused by your morbid obesity
• A psychological evaluation/clearance must be included in a letter of medical necessity written by your primary care physician and provided to the Obesity Surgery Specialists for submission to your insurance company.

What if my insurance denies my claim?

If your insurance denies coverage for the gastric bypass surgery, don't give up hope. In many cases, providing additional information in the form of an appeal letter could result in your denial being overturned. If your insurance carrier continues to deny coverage, you may consider seeking legal assistance. Insurance companies will often relent to avoid confrontation.

Additional Information about insurance coverage for WLS

Most insurance companies follow the recommendations of the National Institute for Health when they set up their guidelines to qualify for surgery. However, some insurance companies have offered “exclusion” to employers when contracting for an insurance policy.  This means that your employer may have elected to not cover the medical treatment for obesity or morbid obesity.

Some insurance companies will require documentation of a history of morbid obesity.  You can easily obtain these records from any physician you have seen in the past.

This includes your primary care physician, internal medicine physician, gynecologist, pediatrician, or any other physician who has kept track of your weight.

Insurance companies will not accept a summary letter from your physician…they will need the actual office visit records. If you have taken any medications that were prescribed by a physician to assist in weight loss, the insurance company will want to see these records.

Records from Weight Watchers, Jenny Craig or other diet programs are generally not accepted for documentation of attempted weight loss, but if you can get these records they may be helpful as supporting documentation.

Some insurance companies will require pre-operative evaluation and clearance for members who have a history of severe psychiatric disturbances or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications.

All HMO insurance companies will require a referral to the treating physician.  They may also require that you stay within a certain list of physicians.  You should check this out with your primary care physician early in the process.

Ask questions

Since you probably still have a big behind (yeah, that is why I write this and why you are here, no?) you have to be a real “pain in the butt”. Call them, write to them, and regardless of the initial policy, ask the company to send you their policy bulletin or treatment guidelines regarding coverage.  This document will tell you everything your carrier requires for coverage.  Pay particular attention to any requirements for diet history.  The lack of documented history is the number one reason requests for this surgery are denied.

Burning Calories While you Sleep

This is a scientific fact, no fiction at all! In my particular case, I burn 2,309 Calories a day without exercising at all! Isn’t that great? Well, yes it is, but there is more than that “extra bonus” you get in life. Read on:

Your basal metabolic rate, or BMR, is the minimum caloric requirement needed to sustain life in a resting individual. It can be looked at as being the amount of energy (measured in calories) expended by the body to remain in bed asleep all day!

BMR can be responsible for burning up to 70% of the total calories expended, but this figure varies due to different factors. Calories are burned by bodily processes such as respiration, the pumping of blood around the body and maintenance of body temperature. Obviously the body will burn more calories on top of those burned due to BMR.

Main Factors Affecting BMR

As we grow older, our BMR will steadily decrease. In youth, BMR is higher, and as we age we have less lean body mass - slowing the BMR. The more lean tissue on the body, the higher the BMR, the more fatty body tissue, the lower the BMR. (This does mean that an individual can raise their basal metabolic rate by undertaking regular exercise). A person's height is also a factor, a tall thin person will have a higher BMR than a shorter, fatter person. BMR will increase in pregnant women.

Short Term Factors Affecting BMR

Illnesses such as a fever, high levels of stress hormones in the body and either an increase or decrease in the environmental temperature will result in an increase in BMR. Fasting, starving or malnutrition all result in a lowering of BMR. This lowering of BMR can be one side effect of following a diet and nothing else. Solely dieting , i.e. reducing the amount of calories the body takes on, will not be as affective as dieting and increased exercise. The negative effect of dieting on BMR can be offset with a positive effect from increased exercise.

The Math

The BMR formula uses the variables of height, weight, age and gender to calculate the Basal Metabolic Rate (BMR). This is more accurate than calculating calorie needs based on body weight alone. The only factor it omits is lean body mass and thus the ratio of muscle-to-fat a body has. Remember, leaner bodies need more calories than less leaner ones. Therefore, this equation will be very accurate in all but the very muscular (will underestimate calorie needs) and the very fat (will over-estimate calorie needs).

Women: BMR = 655 + ( 4.35 x weight in pounds ) + ( 4.7 x height in inches ) - ( 4.7 x age in years )
Men: BMR = 66 + ( 6.23 x weight in pounds ) + ( 12.7 x height in inches ) - ( 6.8 x age in year )

For an interactive Online BMR Calculator, click here.

Avoiding Hunger

Hunger is one of your body’s strongest stimuli, and can be an evil challenger to your will power. Hunger is also relatively slow to subside, and can cause you to eat more than you intended. To break this unproductive hunger-overeating habit, always try to eat before you get hungry. This may seem counter intuitive to someone who’s trying to limit their Calories, but it’s a very effective concept. Two different techniques can help make this easier to accomplish:

Eat smaller, more frequent meals

Instead of three meals per day, try eating five or six smaller meals. By eating more frequently, there will be less time between your meals, and less chance of you experiencing such intense hunger. As an extra benefit, there is some evidence that suggests that eating more frequently can also help raise your metabolism.

Include more slow-to-digest foods in your meals

When it’s not possible to eat more frequently, make sure that your meals contain a mix of nutrients. In particular, fats and protein are much slower to digest than carbohydrates. While most carbohydrates leave your stomach within about two hours, protein takes approximately four hours to digest, and fat takes as long as six hours.

The slower digestion of fats is one of the primary reasons that people on low-carb diets (like Atkins™ and South Beach™) experience less hunger than those on low-fat diets. It’s not necessary to completely eliminate carbohydrates from your meals, though.

Correcting bad eating habits

We eat not only for nourishment, but also as part of our social interactions. However, many people develop unhealthy habits that encourage overeating. So again, you have to change your lifestyle after WLS. Here are a few examples of bad eating habits that you should try to avoid:

Mixing food and entertainment

It’s easy to mindlessly eat a tub of popcorn, a whole bag of chips, or a carton of ice cream while you’re watching TV. Make eating a separate activity, and you’ll consume less. I was advised by my doctors that I should dedicate 30 minutes to eat each meal. This strictly means concentrating 100% on eating, nothing else. I had to learn to put away the newspaper, and turn of the TV, and focus on my spoon fork and knife, for 30 minutes. I know it sounds ridiculous, and believe me, it feels very stupid in real life! But, it is one of the best tricks I have to not overeat. You have to train yourself.

Eating to relieve stress

There’s nothing wrong with taking pleasure from eating, but try not to use food as your primary stress reliever. Find other ways to dissipate stress (such as exercising, listening to music, or meditating) before eating. For me, going to the gym is the best relieve I have found so far. It works great with me because I see my body burning away fat, I feel my muscles work.

Eating on the run

With the abundant availability of convenience foods, it’s easy to grab something from a vending machine and eat your meals in your car. But try not to make this a regular daily habit. Plan your schedule to include enough time to prepare and eat your meals in a quiet place, without the rush.

If you continuously have trouble controlling what you eat, realize that correction of your eating problems may be beyond your own abilities. Consult a psychologist or weight loss professional for additional help. I had to do this many times. I am considered smart and intelligent, and I am well educated and I know what a candy bar can do your body. But, there are other factors within you, that you just can’t control, and expert help is the only way.

Essentials about Successful Weight Loss

Weight loss depends on energy balance.

No matter what WLS you had, the rule stays the same: to lose weight, your energy intake must be less than your energy expenditure. This will always be true. There are no foods, pills, or potions that will magically melt the pounds off. The only approach that works is eating less and/or exercising more. This is why WLS sets you one step ahead; by helping you reduce and restrict your calorie intake. But, you have to do the rest.

Permanent weight loss requires permanent change

Don’t assume that the surgery is the magic solution and after it, you can return to your old eating habits or just spend six weeks on a diet. Short term diets only produce short term results. After WLS the only successful way to keep the weight off is to make small but permanent changes in your lifestyle.

There are many documented cases of people gaining back their original weight, even with the most restrictive surgery. After all, the operation is performed in your digestive system, not in your brain.

In my particular case, I do exercise 3-4 times a week. It does not matter how much you do, or how fast your run, or how much weight you pull at the gym. The secret is to be persistent. Every day counts, believe me: I started to see results a few weeks after joining my gym, and that is very rewarding.

You will also notice that with time, you will be able to eat more, or you will start to tolerate different kinds of food. The good news is that your body is wise and starts to adapt so you can lead a normal life, the bad news is that you will be able to eat food that you should not eat at all. Again, you have to rewire your brain to succeed. I am still struggling with this day by day, but it is easy to deal with, at least, easier than before.

The Best Exercises for Weight Loss

WLS by itself does not guarantee weight loss… exercise can greatly accelerate your weight loss progress. In fact, exercise can help you lose weight in three separate ways:

1. Your body will burn extra Calories while you are exercising;
2. If the exercise is high enough in intensity (i.e. significantly increases your heart rate and respiration), your body will continue to burn Calories at an elevated rate for an extended period after your exercise session has ended; and
3. If the exercise places a high enough load on your muscles, they will increase in size, and burn more Calories even when your body is at rest.

This last item (i.e. muscular adaptation to exercise) is an important factor for weight loss, because it enables your body to burn more Calories at all times. Muscle tissue is more "metabolically active" than body fat. With more muscle and less fat, your metabolic rate is naturally higher.

Muscular adaptation occurs most readily when the load placed on a muscle exceeds about 60% of its maximum contractile strength. This makes weight training one of your best exercise choices, and the most direct path to a sleeker, shapelier body.

How to Get Started With Weight Training

If you're serious about getting results, forget about the fancy machines in the gym and the made-for-TV products. Take the time to learn a few basic free weight movements, including the squat, bench press, dead lift, bent row, and shoulder press. These exercises activate your body's largest muscles, and will have the most dramatic effect on transforming your body. A good personal trainer at any commercial health club will be happy to help you get started.

If you can't afford the time to go to a health club, you can easily set up a weight training area in your own home. It really doesn't require much space or equipment. A good set of dumbbells and a sturdy exercise bench is all that you need. 

What About Aerobic Exercise?

Aerobic exercise (e.g. aerobic dance, running, biking, etc.) improves cardiovascular health and can help you burn a considerable number of Calories. However, aerobic exercise does not usually place enough load on your body to create much muscular adaptation. Because of this, aerobic exercise is not nearly as efficient as weight training from the perspective of maintaining long-term weight loss.

All exercises make weight loss easier, though, so don't choose an exercise solely for its efficiency. The best exercise for you is simply the exercise that you enjoy and are willing to do consistently. Even walking is a wonderful exercise. Walking just 15 extra minutes a day will equate to about a pound of additional weight loss each month for the average person.

If your exercise program becomes boring, look for ways to make it more interesting and productive. For example, a weighted exercise vest could add a new twist to your morning walk. Keep challenging yourself, and exercise will become a very fulfilling part of your lifestyle.

Gallstones and Gastric Bypass

Gallstones are common among obese patients who lose weight rapidly after gastric bypass surgery. Gallstones are not a complication of the surgery as such, but are related to the problem of clinically severe obesity, in general.

Patients who had their gallbladder removed, either before or at the time of gastric bypass, may still develop stones in the remaining bile tubes.

One study found that more than a third (38 percent) of patients who had gastric bypass surgery developed gallstones afterward. Gallstones are most likely to occur within the first few months after surgery.

Gallstones are one of the most medically important complications of voluntary weight loss. People who lose a lot of weight rapidly are at greater risk for developing gallstones. This is very true for us as a WLS patient.

One major study found that people who lost from 9 to 22 pounds (over a 2-year period) were 44 percent more likely to develop gallstones than people who did not lose weight. Those who lost more than 22 pounds were almost twice as likely to develop gallstones.

Other studies have shown that 10 to 25 percent of obese people develop gallstones while on a very-low-calorie diet. (Very-low-calorie diets are usually defined as diets containing 800 calories a day or less.

The food is often in liquid form and taken for a prolonged period, typically 12 to 16 weeks.) The gallstones that developed in people on very-low-calorie diets were usually silent and did not produce any symptoms. However, about a third of the dieters who developed gallstones did have symptoms, and a proportion of these required gallbladder surgery.

In short, the likelihood of a person developing symptomatic gallstones during or shortly after rapid weight loss is about 4 to 6 percent. This estimate is based on reviewing just a few clinical studies, however, and is not conclusive.

Researchers believe dieting may cause a shift in the balance of bile salts and cholesterol in the gallbladder. The cholesterol level is increased and the amount of bile salts is decreased.

Going for long periods without eating (skipping breakfast, for example), a common practice among dieters, also may decrease gallbladder contractions. If the gallbladder does not contract often enough to empty out the bile, gallstones may form.

A meal or snack containing approximately 10 grams (one-third of an ounce) of fat is necessary for the gallbladder to contract normally. But, no studies have directly linked a diet's nutrient composition to the risk of gallstones.

The Evil in Snacking

Gastric bypass patients are instructed to avoid snacking. No exceptions. No excuses.

Snacking is the worst possible thing a WLS patient can do. If patients snack they cease to lose weight and could possibly regain weight. In addition gastric bypass snackers risk severe swings in blood sugar levels and glucose overdose, they fail to move forward to the healthy life that surgery makes possible. They feel like failures when the WLS does not result in weight loss.

The nature of gastric bypass surgery gives patients an edge on beating the snacking habit. When a patient eats three protein-rich meals a day the body’s fuel requirements are met and satiation results. Hunger does not occur if water is sipped throughout the day. If a patient is taking vitamins they will not be nutritionally wanting. Given that, patients who snack are doing so out of the very habit that contributed to obesity.

If a dieter must snack they must be mindful of their choices. Fruits, vegetables and lean proteins will contributed to wellness and weight loss. Processed carbohydrate convenience foods fail to meet nutritional needs or facilitate weight loss and should be avoided.

Successful WLS patients understand that snacking is bariatric purgatory. When they begin to snack weight loss will cease and weight gain will certainly result. Successful weight loss patients – those who maintain their weight loss years after surgery – do not snack. The same is true for all successful dieters regardless of the means by which they initially lost weight.