Panel Members: Milt Owens, MD (our surgeon); Dan Staso, Ph.D. (our
psychologist); Matthew Rice, and BA (our exercise physiologist); Tracy Owens, RN
(our fearless discussion leader)
Tracy:
Let's go around the room and have people introduce themselves:
My name is Rhonda. I had the surgery 2 years ago and I have lost 85 pounds.
(Applause)
My name is Jeanette. I had the surgery 2 years ago and I have lost 150 pounds.
(Applause)
My name is John. I had the surgery 2 months ago and I have lost 36 pounds.
(Applause)
My name is Nancy. I had the surgery 2 months ago and I have lost 51 pounds.
(Applause)
My name is Bernie. I had the surgery 1 year ago and I have lost 138 pounds.
(Applause)
My name is Betty Ann. I had the surgery 20 months ago and I have lost 90 pounds.
(Applause)
My name is Lynn. I had the surgery 3 months ago and I have lost 37 pounds.
(Applause)
My name is Carol. I had the surgery 3 years ago and I have lost 103pounds.
(Applause)
My name is Betty Ann. I had the surgery 20 months ago and I have lost 90 pounds.
(Applause)
My name is Jean. I had the surgery 6 years ago and I have lost 170 pounds.
(Applause)
My name is Michelle. I had the surgery 8 years ago and I have lost 110 pounds.
(Applause)
My name is Sandra. I will have surgery next week. (Applause)
My name is LAShon. I had the surgery 3 months ago and I have lost 86 pounds.
(Applause)
My name is Leann. I have not been approved for the surgery yet. (Applause)
Tracy: For tonight's program we have adopted our panel of experts format. I know
you've met Dr. Owens, or you wouldn't be here. He's our surgeon. Then Dr. Staso,
our psychologist for the support group and then Matthew Rice is our nutrition
and exercise specialist. He's the one that's going to be leading our field trip
to the MGM gym this coming Saturday. For those of you who have not previously
been to this type of support group meeting, it works like this. I hand out
pieces of paper; you write questions that you would like answered, then we
collect the questions and I present them one at a time to our panel.
Tonight, although it is a little bit irregular, I would like to begin with a
question of my own.
Tell me what you think would be the best advice for patients? Is there one
common thread for success with weight control?
We'll start with you, Matt.
Matthew Rice: I would say it's probably similar to the general population. It's
sticking with an exercise routine and being consistent with it. The hardest part
is finding the time to exercise. Nevertheless, it's very worthwhile to make
exercise part of your lifestyle and to really plan on it and schedule it into
your daily life.
Dr. Staso: Number one, I think it's attending these support groups, Number two,
having a regular exercise program that fits your needs and that you can fit into
your lifestyle easily. The third would be having people around you that are
supportive of you. The fourth is having a positive mental attitude. Basically,
those are the four things that I find are the keys to success.
Dr. Owens: To me, it's making a commitment to the notion that you have to manage
your weight for the rest of your life. Part of what that involves doing is
exercising as a regular commitment. I think looking for lifestyle changes that
increase your activity is a very useful thing to keep in your head. Jeanette
would volunteer first in this room if we said we needed some drinks from the
kitchen. Jeanette would stand up and take off. She burns calories doing that and
she does it deliberately as a means of controlling her weight. I think that you
have to think about calories and food choices for the rest of your life. You're
not always going to make the right ones, but if you're thinking about it, you're
going to make it more often than if you don't. The support groups help keep you
focused on where you ought to be in terms of food choices and exercise. But you
really, really, really have to make exercise part of your life.
Tracy: Dr. Owens, at what point in time does a patient need to get a lab
analysis post-surgery?
Dr. Owens: I don't think there's a hard and fast rule to that. Some of it
depends on whether there's a degree of malabsorption in the procedure.
Deficiencies need to be watched for more carefully if some degree of
malabsorption has been surgically created as part of the gastric bypass. If
you're thinking about routine follow-up for vitamin deficiencies or iron
deficiency, if it's a regular short-limb gastric bypass, then maybe after six
months to a year. It's pretty unusual to see somebody get in trouble if they're
actually taking their vitamins and their iron. If they are, I tend to not worry
too much about checking their lab work.
There are a lot of modifiers to that: Will the insurance pay for the lab work,
and that kind of thing? Mainly, if people are doing well, I don't I follow a
hard and fast routine. I think a lot of people would be more comfortable if we
did lab work every six months for your life, but often that is not cost
effective or necessarily the right way to go for other reasons. Usually I do
screening labs if nothing has been done for a year or two or if there is cause
for concern as when someone has neglected to take their supplements. Bone
density is probably worth checking every two or three years as a routine.
Tracy: Dr. Staso, what do you recommend in terms of dealing with friends who
seem to have difficulty accepting the "new you"?
Dr. Staso: You will have a lot of people that come in your life and go out of
your life, but your true friends stick by you. The people that leave you are not
your true friends. They have to come to terms with your weight loss. Don't kid
yourself. Not everybody is going to be happy for you. They're not worth it
anyway if they can't support you. Unfortunately, it happens a lot.
Matthew, what is your opinion about the recent "carbohydrate diet, as recently
shown on Oprah? What do you think about the Atkins' Diet? This was featured in
People Magazine.
Matthew Rice: Nutrition is very complex, first of all. For those of you who were
here earlier this year, I gave a talk on the latest diet crazes. My basic point
was that these diets were working because they are low-calorie diets. The goal
if you are trying to lose weight is to restrict your caloric intake. No matter
what types of food you are eating, you are going to lose weight if you are
taking in fewer calories than you are burning. It doesn't matter if you are
taking in just carbohydrates, just protein or just fat.
After bariatric surgery it's important that you make good food choices, because
you don't have the capacity to eat as much. Protein-only foods are not
necessarily the best. You need to get carbohydrates from quality sources like
whole grains, fruits and vegetables. Those are not bad. Everyone is saying
carbohydrates are bad, but they are not.
Dr. Owens: I have a question for Matt, but I'd like to direct one to the
audience first. How many of you know something about weightlifting, anything at
all? How many of you know what a set is? Yes, a set is a number of repetitions
until you get tired. Matt, I read an article just recently, and they said as
though it was an accepted fact that one-set workouts with weights were better
than several-set workouts. What do you think of that?
Matthew Rice: That's pretty new. Several studies were done a few years ago at
the University of Florida on that. For the untrained population, they showed
that doing one set of an exercise was as effective as doing three sets. But
since then they've done studies on trained people, people who have been training
for over six months, and it's shown that multiple sets are more effective than
one set, once you've become trained.
Basically, when you haven't been exercising or haven't lifted weights in the
past, it takes very little to stimulate your body and to make it respond to the
training. Doing one set is plenty if you've never lifted before. Once you get
into a routine and get more conditioned, you are going to see greater benefits
with two or three sets for exercise.
Tracy: Dr. Staso, this is a patient who has been told she needs to exercise
three times a week. First I'll ask Matt why?
Matthew Rice: In general, three times a week is recommended to see minimum
benefits from a health perspective: to reduce your risk of heart disease, and
certain forms of cancer.
From a weight-loss perspective, the more calories you burn, the better off you
are going to be. It's always going to be how many calories you're taking in
compared to how many calories you're burning. The more calories you burn through
exercise, obviously, the better off you're going to be. Three times is the
number that most people can start out at and maintain.
If you try to exercise seven times a week, chances are you're setting yourself
up for failure, and that's going to do a lot of psychological damage over time.
If it can't be fun exercise should at least be tolerable for long periods of
time. A routine with some variations often works best.
Tracy: Some of us are working parents or have other things going on at home, we
really don't have time to spend 45 minutes doing something. Could you do a
little bit in the morning and then do a little bit in the evening? Does it all
add up or do you have to keep that heart rate at a certain pace in order for it
to be effective?
Matthew Rice: That's a very good question. A lot of studies have been done on
that recently. As long as they are in about 10-minute bouts, exercises will add
up and give you the same benefit. It used to be thought that you had to exercise
for a minimum of 20 minutes at a time, and even more than that was more
beneficial. Now it has been shown that for both weight loss and cardiovascular
health that it will add up, as long as you're doing 10 minutes of elevating the
heart rate and maintaining it there. This is good to know when people have short
breaks.
Dr. Staso: There are two reasons why I think exercise should be three times a
week. The first is that most people are aware that exercise reduces your level
of stress. When you work out, your body feels better. Emotionally, you do
better. It also prevents or at least helps to reduce depression.
The other reason is that a lot of people that I interview have a
self-sacrificing personality, which means they want to take care of other people
first. They feel a little guilty when they turn around and take care of
themselves. For you to be successful for long-term weight loss, you must be
willing to take time out for yourself. It's a real learning process. It requires
an attitudinal shift.
I think one of the reasons that some people are more successful than others are
not just because they exercise, but because they have the motivation to take
care of themselves. They take the time to take care of themselves. Usually
people who self-sacrifice a lot have anger inside of them they really don't know
how to express. They get caught in the trap between resentment and guilt. If
they don't do something, they feel guilty. If they wind up doing it and really
don't want to do it, they feel resentment. Learning to take care of yourself is
a fundamental feature in being able to keep your weight off for a long period of
time.
For working mothers it's difficult. How are you supposed to take care of
yourself without neglecting your kids and your family? There's not an easy
answer to that, but it still goes back to some things are negotiable and some
things are not. Carving time out for you is not negotiable. You must be willing
to do that.
For some people the problem is in getting help from their family. I'm a busy
person. How do I get other people to rally behind me and to do some of these
tasks and to take over some of the responsibilities?
Sometimes it means asking directly for what you want. Other times it means
letting go of a perfectionist streak. If you have to have things done a certain
way and you won't let anybody else do it because it's not the way that you want
it done, it would be important to learn to let go of that, if the alternative is
to not have time for yourself. Learning how to take time for you might mean
letting go of that standard and just relaxing about it.
Tracy: The other part to the question from the person about exercising three
times a week, the second part of the question was how do you keep yourself
motivated, because motivation is an important part?
Dr. Staso: Obviously, you have to want something. I think in the case of
motivating, one way of doing this would be to keep asking yourself what is it
that you personally want for yourself in your own life? What are you willing to
do to get it? It isn't easy to sustain that kind of motivation all the time.
What I advise is the buddy system. I've said many times that when you come to
meetings like this, you have a rare opportunity to network with somebody who
shares a very, very similar problem. If you keep coming and you keep talking to
people, sooner or later you're going to find one other person that you can
resonate with.
Make that person your buddy. Encourage each other to stay on this exercise
program. As you get to know each other, become better friends, you become better
support for each other. Sometimes just a little leverage of calling somebody up
and saying you know, I just don't feel like working out today. Your friend might
say that's tough, go ahead and do it anyway. Or you can meet somebody for a
walk. Just teaming up with somebody can make a huge difference.
Matthew Rice: Generally, most people who join a gym end up not going after a few
months. Obviously, results are one thing that definitely motivates people. Make
sure you are on a structured, well-thought-out training program that's going to
help with that goal. A lot of people don't ask enough questions from people in
the gym they're going to. They don't go to a personal trainer ever to find out
what they should be doing. That kind of hurts them in the long run, because then
they don't quite see the results that they would like to see.
Exercise is not going to change your body completely overnight. A lot of people,
after a week weigh themselves. Oh, I haven't even lost any weight, what's all
this work for? I have been going to the gym for a whole week! I hear that all
the time. You have to let your body adapt and make the changes because there's
no quick fix. If it were very easy, there would be a lot more thin people
walking around. It's not easy. That's the bottom line.
Also, as Dan was saying, the buddy system is great. There have been studies
showing those married couples who go and train together have much higher
adherence rates than couples who don't. Whether it be a friend or spouse or
anyone who you can find to exercise with and fit that time in, it generally is
going to help you in the long run to stick with the program.
Dr. Staso: I want to add just one more thing. All of us are creatures of habit.
It's very common for a person to say, you know, it would be a good idea if I
made this behavior change. So you make this behavior change for three or four
days, and then a couple of days go by and you realize you forgot to remind
yourself to make that behavior change. Then you go back and you make the
behavior change again, and you might be good for a couple weeks. Then two weeks
will go by and you realize wait a second; I haven't done this behavior in two
weeks. How am I ever going to get myself to change this habit?
The way you do it is with patience and persistence. It does take time and a lot
of patience to change old habits. You can do it and it is done. Some people say
it takes 21 days to break old habits and another 21 days to form a new habit.
That's six weeks to change.
Once you have made a decision that it's in your best interest to make behavior
changes, I encourage people to adopt the idea that there will be no exceptions
and no excuses. So I have people memorize that, no exceptions, no excuses. Why?
Because you need a justification. You're going to hear the voice, oh; I'm too
tired today. I don't have time today. I'll do it tomorrow. It's not convenient.
This is happening, that's happening. There are always a thousand and one good
reasons why you shouldn't be exercising when in fact you should.
The rule is no exceptions, no excuses. You just do it. You make it happen.
Tracy: I was told that it takes 21 days to give up a habit. if you break that
cycle anytime in between, it's 21 days again. You have to start that cycle all
over again. Is that really true.
Dr. Staso: I don't think there's a set rule that you can use for that.
I would say you could make the behavior change in as fast as six weeks. Most
people can make behavior changes reasonably well within a six-month period of
time. Old habits are not easy to break, but they are breakable.
Matthew Rice: A good example is in the gym business, come January 1st, the
membership crew is gearing up for huge numbers. Everyone is making New Year's
resolutions, but, surprise, in February, the gym is back down to normal, but we
have higher membership numbers. It's very, very common that people start with
good intentions but do not follow through.
But if you miss it is important not to beat yourself up too bad. Don't obsess on
it and say, well, it's obvious I can't keep this up, so, what's the point?
Always get back into it as soon as possible. It gets easier and easier the
longer you go without working out to make excuses and say it's just not going to
fit in with my lifestyle. So get back to it as soon as you possibly can.
Dr. Staso: I think it's the difference between being on a diet and being on a
lifestyle change. When you're on a diet, it means at some point, you're going to
be not on a diet, by definition. When you make lifestyle changes, the goal is to
create something you can do for the rest of your life. It's not a short-term
thing. It's the rest of your life.
Q: Why, after gastric bypass surgery, is it necessary to take Trinsicon forever?
Dr. Owens: Because of the gastric bypass food doesn't pass through the main part
of the stomach. As a result you don't absorb B12, iron and calcium as well as
you might. For some people that will mean a deficiency, and over time that means
deficiency symptoms, only some of which are reversible. The safest thing is for
everybody to take extra amounts so nobody gets deficient. There is no down side
to taking too much.
Q: What about iron?
Dr. Owens: Yes, with iron, it's possible. With calcium and B 12, you can't take
too much. With iron, although it is possible, in general it is pretty hard to
take too much, particularly after this kind of surgery.
Q: Ever since that surgery, I find myself having a lot more gas. Do you have any
reason why that might be?
Dr. Owens: Often it's due to undigested food arriving in the colon. It's not
unusual with meats, particularly steak, beef and lamb. Because it's not as well
digested. It's also possible to be due simply to dairy products, because all of
us, as we get older, don't digest milk sugar as well. Milk sugar, when it gets
to your colon, produces gas. The gastric bypass tends to make lactose
intolerance somewhat more severe in many people. There are a variety of things
that have been tried and work sometimes, like activated charcoal, chlorophyll,
Beano, and the avoidance of certain foods know to cause the problem.
Q: What are the signs of pernicious anemia?
Dr. Owens: It's B12 deficiency. It presents quite like multiple sclerosis.
People get numbness, unexplained numbness, or unexplained inability to move.
Sometimes blindness. You don't want to wait that long, because it may not be
entirely reversible when you get the B12 back. Hence the need for continued
supplements.
Q: What medical and psychological issues would disqualify a patient from having
gastric bypass surgery?
Dr. Owens: There are certain contraindications. You don't want to be pregnant.
The extremes of age are to be avoided: the very young and the very old. Although
we are doing more teenagers and more people over sixty than we used to and some
centers are doing preteens. Active drug or alcohol addiction would be another
disqualifier. An overt psychosis I think would probably be another. Previous
surgery on your stomach, particularly hiatus hernia repairs, make it very
difficult to do a gastric bypass and might be a reason for doing a different
procedure.
A recent heart attack is a contraindication to elective surgery of any sort,
recent being within six months. You wouldn't want to operate on someone whose
life expectancy, due to some other illness, is so short that they would never
enjoy the improved benefit and life expectancy that you get from losing the
weight and having the surgery. I don't think it would be a good idea to operate
on somebody who has AIDS.
Many previous abdominal operations, inability to chew or exercise, and a lack of
motivation to make life style changes. All are important relative disqualifiers.
Dr. Staso: I would disqualify, anybody who has an active history of alcoholism,
substance abuse or psychosis.
To a lesser extent, those who have a manic-depressive disorder. It really
depends upon the severity of the manic depression.
Those who are marginal are one who has a history of emotional instability. I
carefully check individuals who have a history of eating disorder. Bulemia and
anorexia are relative contraindications.
I always ask potential patients what kind of support do they have in their life?
Somebody who lives alone, doesn't have any friends, doesn't live close to family
and who doesn't live very close to a support group, I think, is going to have a
hard time managing long-term weight loss.
I think those who do the better are the ones who have supportive family and
friends
I have to differentiate between depression that's endogenous versus depression
that's caused by obesity. I find that about half of patients are depressed, but
that doesn't mean I'm not going to qualify them. Oftentimes their depression
goes away when they lose their weight. Some become depressed afterwards who
weren't before.
Every case is a little different. Rarely, I would oppose surgery because of
depression. Sometimes I postpone surgery if they need to get on the appropriate
medications or get back on medications or get connected to a psychiatrist. I
might recommend they get into counseling if it's indicated.
Q: Is there a recommended number of calories that should be consumed at
different stages after surgery?
Dr. Owens: Fewer than you're burning would be the ideal number, at least until
your weight is normal. In terms of a specific number of calories so that you can
go and check and look at things, I don't think that makes particularly good
sense. It's too hard to do, for one thing. Nobody's going to calculate
consistently. Very few people are going to be willing to do that. It's much
easier to try to develop overall good eating habits, avoid fats and don't snack.
Matthew Rice: Even if you were willing to diet by numbers, it's very hard to
figure out what your metabolic rate is. Unless you got to a physiology
laboratory. You have a lot of different calculations to figure out. As a rough
approximation, multiply your weight by 17, and that's how many calories you need
to eat. But that assumes that you are not overweight. Most calculations are not
very accurate because everyone is so different. A lot of it depends on your
basic genetics and then how much muscle mass you're carrying.
Q: Dr. Owens, you said that over time while you're eating the pouch would get
larger. Do you have to get like a touch-up or a tightening or have more surgery
to keep it small?
Dr. Owens: No. The whole GI tract is quite accommodating. Things stretch and so
on, but typically you'll end up eating small adult meals for the rest of your
life.
Q: I know that I eat a lot less than I did, a whole lot less but much more than
I think that I should be able to eat. I am worried that I will begin to gain
weight again.
Dr. Owens: We can get an x-ray and see if your pouch is bigger than it ought to
be. If it is, we could go back and redo the surgery. Often, however, that
doesn't work really well in the sense that initial good results are often
followed with a recurrence of the same problem.
In about 5% of people there is substantial postoperative weight regain. It's a
tough problem. When evaluating people who have regained a lot of weight or who
seem to be able to eat a lot I am often conflicted. On the one hand I would like
to help them, but I don't want to put them through another operation where the
risk is twice what it was the first time around. But the choices are repeat
operation-- sometimes adding a change that interferes with absorption of foods--
or renewed attempts at diet, exercise, support groups and medication.
Fortunately, most people do better. There's an accommodation. The pouch gets
somewhat larger, but people's habits get better. They end up being pretty well
off, most of them. There's a wide range. If you look at the bell-shaped curve on
weight-loss distribution, let's say, at two years, everybody's in there pretty
tight. The minimum anybody's lost is about 30-40% of their excess and the
maximum is 100%.
At ten years, the curve is much broader. There are people who are coasting
along, just doing fine. Every now and then, somebody walks in the office eight,
nine, ten years later, and they look like they've never been overweight. You'll
see people on the other end of the spectrum that are way back to where they
were, and some a few pounds beyond.
I think that depends, undoubtedly, on genetic mechanisms we don't understand.
Not everybody's overweight for the same reason. Also a lot depends on behavior
patterns: Matters that are within your control to a much greater extent. That's
why we emphasize the exercise and the dietary choices, and lifestyle choices.
Q: How can you build muscle? Is it more weight or more reps?
Matthew Rice: Basically there is a repetition continuum, and different things
occur to muscles at different repetitions per set. Recall that a repetition is
one exercise motion and a set is that motion repeated to exhaustion.
Generally speaking, you want to do repetitions until you have fully fatigued the
muscle. If you plan to do 10 repetitions per set, try to choose a weight that
you can put through that motion only about ten times before further exercise is
prevented by fatigue. .
Generally speaking, to build muscle, you want to do between 8-12 repetitions. If
you go less than that, you're going to build slightly more strength, but not as
much muscle. There is a common misunderstanding. People think you have to lift
very heavy weights with really low repetitions to get big. The example I use is
the difference between a body builder and a power lifter. Bodybuilders are much,
much larger from a muscle-mass standpoint than power lifters. If you've seen the
Olympics, those are very large men, but their muscle mass isn't nearly as big as
the body builder isn't. They're doing different workouts. The power lifter is
much stronger, but the body builder is more muscular. That's due to the fact
that the nervous system gets trained more effectively on lower repetitions and
that's where most of the strength component comes from.
Muscle mass is built and it does have strength, but not as much as the nervous
system can. So 8-12 reps is for building muscle. As you go higher, like 15-20
reps, that's going to be more towards muscular endurance, which is not going to
build as much muscle. We'll talk about all this at the field trip. Lower reps
for strength, medium reps to build muscle and higher reps for muscular
endurance. If your objective is to lose weight you want to work towards
increased muscle mass primarily.
If you do a proper cardiovascular warm up, you can pretty much jump into a
working set where you're handling 8-12 reps. If you haven't weight-trained
before, that does seem like a very heavy load. Once you're better conditioned
it's not. If you can do it 12 times, it can't be that extremely heavy.
Q: How much resting between sets?
Matthew Rice: Generally about 60 to 90 seconds.
Q: What is the most common stumbling block for patients post-op2 Does that
change as the post-op time changes?
Dr. Owens: Exercise.
Dr. Staso: Compliance with the recommendations from this program. They are
pretty straightforward, and most patients are knowledgeable about them. So I
think it has to do with a willingness to comply with what is recommended on a
consistent basis.
Matthew Rice: Hopefully you know what my answer is. Exercise adherence is a big
stumbling block for everyone, particularly this population that has not,
generally speaking, been exercising a lot in the past. It's even harder for
people who are not in the habit of making exercise part of their lifestyle.
Tracy: I want to thank all of you for participating tonight. Thank you Dr Owens,
Dr. Staso, and Matthew Rice. And congratulations to all of our patients who have
shown the enthusiasm to be here tonight and the discipline to lose all that
weight. Goodnight. And drive carefully.
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