It has been a year since I started treating people with  and without surgical weight loss procedures.  My program includes daily to weekly email followup, monthly office followup and cycling medications for optimal effect.  People who have approximately 60 to 80 pounds to lose can drop 30 pounds in the first three months of the program.  When they are off medications the goal is slow loss or maintainance. 
I try to encourage exercise after the first month of weight loss.  Exercise will always enhance weight loss but mainly helps with weight maintainance while off medications.

There has been increased evidence that the combination of phentermine and topamax have an additive effect on weight loss.  The phentermine helps with appetite suppression and the topamax has an effect on your taste buds that reduces the appeal of the food you are eating.  Like all medicines for  weight loss there is a decreasing effect over time but it seems that the combination of the two drugs has a longer effect than other medications alone.  Medications have side effects and you should always discuss taking medications with your doctor and understand when you should stop them if side effects occur.

The best way to lose weight after you have your band surgery is to eat a meal that will eventually be the maximum amount of food that will fill you once your band is completely adjusted.  I tell my patients that it is better to fill your band into your diet rather than eat into your band fills.  If you watch what you eat during the period of band fills you will lose more weight and not have as many episodes of vomiting or feeling nauseous. 
Normally about 3-4 oz of your protein and 4 oz of vegetables will fill you once your band is adjusted properly.

Patients who have had weight loss surgery need to maintain their protein intake.  An intake of about 60-80 grams of protein daily is a good goal.  Most of the supplements are whey protein based which is milk protein.  Some examples of products are the following: (Note I do not recommend any specific product, you should sample different types and see which one you like)

IDS whey liquid protein bullets:  3.1 oz   42 gms of protein   176 calories

Isopure whey protein drinks:  20 oz    40 gms of protein     170 calories

EAS whey protein products   1 scoop of powder    23 gms of protein    120 calories


There are many other products on the market and most are similar with different additives to change flavor or consistency.  Most powders taste better if mixed in skim milk and this adds some calories about 90 for 8 oz of skim milk and some more protein.

Do not buy large quantities until you taste each product.

For almost ten years I have been presenting information on weight loss surgery at monthly seminars.  For many of those years there was not complete and accurate information about the procedures and about the complications and risks of having surgery.  Now there are many sites on the web but just a few offer easy to understand information that is accurate and easy to understand. 

The following sites are good places to start:  1. www.sages.org and on the home page in the right side of the page is a link to morbid-obesity info.  On this site click on presentation and a power point presentation will be opened.  This site offers a nice over view on the back ground and basis of obesity.  It gives you information on banding and gastric bypass.  2.  www.bariatricedge.com is a site that is sponsored by Ethicon who is owned by J&J.  The site offers comparisons of banding and bypass and allows you to watch an animated video on each procedure.

The other important points that are not on any websites is how you get to have surgery and what is the process.  The following is the best information for the majority of people who have private health insurance.  First almost all of the insurers require a nutritional consultation and a psychological consultation.  Second the majority of insurance companies require 6 months of medically managed weight loss within the past two years.  This means seeing your primary care doctor for six visits, one per month for six months, just for weight loss.  Only a few companies do not require this.  Always check with your insurer about there requirements.

Once you have completed these requirements the remaining things like labs, tests will be determined by your doctor.

Which procedure you choose depends on your preference and a open discussion with your physician.  I always respect my patients wishes and at the same time will give my opinion on what I think will work best.

My patients can be my best source for writing about relevant topics.  Today a patient who had bypass surgery about 4 years ago was in the office to discuss revisional surgery.  I always make a point to include an examination of what has been going on with someones diet over the past year as part of the solution to weight regain.

What was interesting in the conversation was that overall her diet was not bad however on looking into the diet further she was eating a lot of fruit.  Fruit in small amounts is fine but fruit has a lot of sugar.  Of course fruit has vitamins and fiber.  But you can get all the vitamins you need in your multivitamin and your fiber by eating leafy green vegetables that have no calories.

When you are trying to lose weight is important to look at all aspects of your diet to find areas where you can get the same nutritional value of a food without of all those calories.  Always be careful of eating any food in excess.  And what I say in almost every topic is it is all about total calories!

When you finally get to your goal weight its time to celebrate.  How do you maintain that weight?  Of course you must watch what you eat but the most essential thing is exercise.  Exercise will allow you to eat more calories and maintain your weight.  The problem with weight maintenance is that you have been denying yourself those foods that put those pounds on and now that you have got to your goal weight those foods look even better.  If you exercise that will allow you to eat those calories without putting on pounds. 

And of course on the flip side if you exercised the entire time you dieted and decide that once you reach your goal weight you can cut back on your exercise routine, you will be sorry.  The pounds will come back. 

Remember your weight will always be about total calories consumed minus total calories spent.
Anything that upsets the equation can lead to weight gain.

For people who have gained weight or have not reached their goal weight after bypass surgery there is a procedure called Stomaphyx.  The procedure is also for patients who have developed dumping syndrome after stretching their connection between the stomach and small bowel, i.e. gastrojejunostomy.  There are two aspects to have a good result from the procedure.  First the procedure needs to be performed well and second the surgeon needs to have a nutritional plan for the patient after the procedure. 
I put emphasis on the post operative diet.  I want my patient's to understand that there is an opportunity after the procedure to re-learn how to reduce your calories and maintain a satisfying diet.  The first week after the surgery you should stay on a liquid to puree high protein diet. Foods for this week include various protein drinks, low salt soups, yogurt, cottage cheese and pureed meats.  The second and third week your food should be solid but soft and moist. Foods like soft and moist fish, mashed potatoes and tomatoes.   And by the forth week you should be eating regular food. 
The key to successful weight loss is to keep track of how many calories you are eating each week so that as your meal selection changes you continue to maintain the same amount of calories and protein.  This gives you an understanding of how your weight loss is related the amount of calories you are eating.  I have created a free web site call www.myphonediet.com which can help you with tracking and recording your foods, calories, protein, fat and carbs as well as weight.  The site will also help with calculating a calorie goal for daily calories.
The more you understand how your weight changes as your calorie intake varies the more control you will have in keeping your weight off and reaching your goal weight.

Every week I see patients who I have operated on many years ago and they are coming back to my office after having gained some weight.  Most of them admit that the weight came back as a result of going back to the foods which caused them to gain the weight in the first place.  How can that be?  Didn't you believe that after the surgery you would never be able to eat those foods?  What tends to happen is that you can not eat as much of those foods at one sitting, however if you begin to graze or eat little amounts at multiple times than you get in a lot of calories which leads to weight gain.  These habits creep up slowly and the weight comes on slowly.   Weight gain after bypass surgery is slow but hard to remove because your body is very efficient and to get those pounds off you really have to reduce your total calories. 

That is why I created a free website for my patients to help with calorie counting and understanding how your weight is effected by total calories.  The site is www.myphonediet.com.

I like to use the analogy of a hour glass to help people understand the way a gastric band works.  The gastric band creates an hour glass effect in the stomach.  Where the band goes across the stomach it creates a small upper stomach.  The outlet of the small stomach is small and the size of the outlet is adjusted by placing sterile water into the port of the band.  Just like an hour glass if you drink high calorie liquids, i.e. milk shakes, ice cream, alcohol, the fluid will empty quickly.  There is no sense of fullness and the effect of the band is lost.  At the other extreme if you do not chew your food well, it is like putting stones in an hour glass.  The food just won't go past the band and you end up throwing up the food.

The way to use the band for the most weight loss effect is to chew your food well to the consistency of thick sand.  Then the food will empty slowly and you will feel full for a longer period of time but not have any nausea. 

There are three goals that you should meet to use the band successfully: 1) If you eat 3 oz of a protein that is meat, fish, or poultry, with a small amount of vegetables and feel full, 2) you should be satisfied with that meal for 3-4 hours and 3) your weight should drop by 1-2 pounds per week during your weight loss period.

The foods to eat should always be moist and be high in protein and low in fat and carbs.  Examples of this are fish, poultry, meats, whey protein based foods and supplements, and soy or tofu.  If you eat lentils and beans you must be careful about how many carb calories you take in everyday.  Once again weight loss will only occur when your intake of calories is less than you needs.