April 16, 2004

<distressed> please tell me guidelines for gastric bypass (weight vs. height bmi etc)

<Dr. Simpson> Dear Distressed: there are a number of factors, but the basic one is simple: a bmi of 40, or if your bmi is between 35 and 40 then you should have a co morbidity.... that is an obesity related illness, which are -- very specifically -- sleep apnea, heart disease, diabetes, hypertension, or joint problems related to obesity (as in they won't replace a joint because of the weight). That is it. Insurance companies might have a few more, check with your policy.

<Kelsey> I haven't lost weight in 2 weeks. I am 4 weeks out. Is this normal? How much food would you recommend a person at this stage be eating per meal and how many meals?

<Dr. Simpson> Well, you have reached a plateau--- nope you have NOT>>>>> a plateau is when you don't lose weight -- OR INCHES --- for four weeks. How much food -- well, depends on what surgery you had-- but it goes like this, your surgeon should tell you how large your pouch is, and that is how much you should be eating at a maximum. For example, if you have a one ounce pouch-- then eat one ounce...not more than an ounce, and you should eat three to four meals a day with two snacks -- no grazing. Good luck.

<Matt B> I had the surgery, 2 months ago, and I have only lost 25 pounds, I am on soft foods, I seem to eat more than 2oz of food, should I be eating more than 3 meals per day? should it be more like 6-8 small meals? <Dr. Simpson> No it should not be six to eight small meals -- that is grazing. Four "meals" per day, and by the way...get off the soft foods and onto regular foods. In terms of how much you eat -- well, your pouch will stretch...but do not stuff it --- measure twice, eat once, vomit and stretch never.

<beach/va> Welcome Dr. and thanks for giving us your time. I would like to know how a large Stoma is determined and what can be done about it?

<Dr. Simpson> We make the stoma a specific size, less than half and inch. Sometimes they stretch because of things like people stuffing food down there that is too large or overstuffing the pouch and that will stretch the stoma. In terms of what can be done about it...well, sometimes if the stoma stretches we have to go to surgery. If it is too much you need surgery...otherwise sometimes a gastroenterologist can do something called sclerotherapy to scar down the stoma a bit. Good luck.

<kathleen g> Hi Dr. Simpson: Please explain how far out a post-op patient is still at risk for a hernia. I understand there are several different kinds. Thanks.

<Dr. Simpson> You are at risk for hernia the rest of your life....once you have had any surgery, that part of your body is weakened, and while at six weeks most normal people are about 60 per cent healed, patients who have had weight loss surgery take longer as some are a bit malnourished because of not taking in enough protein. So, your greatest risk is about one month after surgery when you forget you have had surgery and try to lift junior to put him on your lap or your girlfriend, for that matter-- but this is a family chat, so we won't go there but you will always have a weakness where surgery was done, and will always be at risk for hernia formation.

<missSweetThang> I am dying to get a copy of your book, is it out yet????

<Dr. Simpson> Ah, hi mom. The book is being printed by the great printing presses in the North as we speak. Once it is fully printed and shipped, there will be big banner ads here on obesityhelp and on my website we will have them. The site to order the book will either be the obesityhelp.com bookstore, or from my website -- or from the site which will be up to place orders www.obesitydr.com. In a couple more months it will be available on amazon.com, barnes and noble, etc. <robert> i am 5 weeks post-op from a rny lap i have just started on soild foods there are times i throw it back up or it feels like a lump in my pouch what can i do to help stop this from happning in the future

<Dr. Simpson> Don't eat so much. Cut your food into smaller pieces, and measure twice, eat once, vomit never.

<brenda> I am just starting to research whether to have the surgery or not, how can I be sure I find a good doctor?

<Dr. Simpson> Several resources are available: The first is to check the American Society of Bariatric Surgery...asbs.org, to see if the surgeon is a member...also, obesityhelp.com has a good site to check a surgeon's credentials...Finally, if your surgeon has a copy of my book in their office than they are CLEARLY above average.

<kathleen g> Hi Dr. Simpson: Please explain how far out a post-op patient is still at risk for a hernia. I understand there are several different kinds. Thanks. <Dr. Simpson> Answered already. Scroll above.

<Karen S.> Hi there! I believe I need a revision. I weigh 190lbs-lowest weight was 171lbs. Got pregnant-first pregnancy at age 39! Cannot lose-feel like I have constant heartburn. Could I be a candidate for a revision? Thank you

<Dr. Simpson> The mI don't think that you need a revision, I think that you need a bit of help with what you are eating....And no, you are not a candidate for a revision unless there is something that is physically wrong with the surgery that you had...For example, a large stoma, or a large pouch, or a leak, or something like that. You can always lose weight, that is something that anyone can do. But you have to figure out your activity level, and your calorie consumption. When patients come to me for a revision I first make them purchase a band to help them with that, which is made by Roche -- at www.healthwear.com -- that will assist in determining the calorie intake to output balance. Then we go from there. Good luck.

<kathleen g> TGIF Dr. Simpson: The other day a BS (bariatric surgeon) said that when BSs personally have WLS, they always go with the lap band. Can you please comment? Thank you.

<Dr. Simpson> That is not always the case, because a number of surgeons have had surgery, and there are a number who have had various forms of surgery. But lap band is the current trend, and probably will supplant the RNY as the major weight loss surgery in the United States. The reason is that it is, by far, the safest surgery that we do. While some will say that other surgeries have more weight loss, that isn't always the case. Something to research for individual patients.

<Marcy Northrup, Tamp> I was wondering..it is necessary to undergo the intense psychiatric evaluation prior to the surgery?

<Dr. Simpson> I don't know what you mean by intense, and most of the individuals who we have test patients do not do "intense" testing....they are simply another level of checking for mental illness, including depression. If a patient has depression we want them to be treated for a month before surgery. Or if they do not understand something, we want to know about it. So, it isn't intense, but necessary it is.

< Eileen NJ> I had surgery back in May of 2003. I have been very weak and fatigued since I had a stomach virus in January. Bouts of diarhea every now and then. Any ideas of what could help me?

<Dr. Simpson> Hard to make that diagnosis over the internet, but could you put your parts up to the USB port so we can examine them carefully? Insert colon into the USB port and allow the camera to scan (nevermind)...I think that you need to see a doctor and make certain that you don't have anything else going on with your body. Could be a number of things, including anemia, and the diarrhea could be from any one of causes...SO go see your doctor, since you didn't want to have the camera placed. Good luck.

<brenda> can laparoscopic surgery be just as good as the full blow procedure?

<Dr. Simpson> We try not to blow it. Yes, it can be.

<Tater-tot> How long do people have to take Lovenox (blood thinners) injections?

<Dr. Simpson> It depends on a lot of different factors. Some take it only while in the hospital, and some for a few weeks afterward...some, if they have a problem, will be taking lovenox for six months.

<Marcy Northrup, Tamp> I've done a considerable amount of research on the Gastric Bypass. Given that info, is it still necessary for me to attend the seminars prior to getting surgery?

<Dr. Simpson> I cannot tell you how many people come to my office and tell me about all the research they have done and we have them attend classes and discover that there is a lot that they do not know. So, since it is impossible to gauge what a person does or does not know by the research that they may have done, seminars are important to get to know the surgeon, and if you like the cut of their gibe. And classes are important to attend because we teachers like getting apples from our patients.

<MeemawT> Dr Simpson ..I had the jejuno ileal bypass in 1977 and reversed in 1991...have had no problems ..I am scheduled to have the RNY in june do u forsee any possible problems and have u ever done surgery on a jejuno patient?

<Dr. Simpson> I have revised a number of patients with the JI bypass, and in terms of problems, well, if they are familiar with you, and the JI bypass, then there should not be a problem at all. I think you will do just fine. You might have a few adhesions, but that is ok-- we surgeons have scissors for those. Good luck.

<Linda Rojas> Is there any programs to help people on medicaid or that have little to no insurance and have no finantial means to pay for this surgery?

<Dr. Simpson> There are some companies who are medical finance companies that put in payment plans for patients and the federal government has said that this is deductible for tax purposes. But other than that --- save your pennies.

<kathleen g> Dr. Simpson: I have bilateral AVN. The first hip was replaced last June. I had RNY 7 weeks ago. The other hip will be replaced in July. Today I heard from someone with similar circumstances, who said that when he had his second hip replaced, he was found to be extremely malnourished due to the small amounts of food he was eating. It caused complications post hip replacement. He and I both take our supplements and eat lots of protein. Should I be doing something more to prepare? Thank you.

<Dr. Simpson> Well, I don't think there is anything more you can do to prepare for a hip replacement, but that is a surgery which is near and dear to my heart, and hips. You can be checked for some nutritional labs to make certain you are eating properly, and you can see a nutritionist. But somehow I doubt that his problems were related to WLS -- although they could have been. While patients do become malnourished for a bit, it is not enough that you don't heal your wounds -- you might heal a bit slower for a bit, but you will heal...and you might be a bit more susceptible to infection, but that is a normal sequence of events following surgery.

<Tater-tot> Is a 30 cc pouch on the small end?

<Dr. Simpson> That size pouch is the normal size that we make them -- at least for the RNY or the lap band.

<Shahla-120lb-8m-po> I am feeling extremely tired all the time.....I am taking my protein and vitamins like I am suppose to....but still feel too tired and sluggish....

<Dr. Simpson> Then you should see your physician and have them run some laboratory tests of your blood. If you want to know which ones, you have two ways of knowing -- the first, and best, is to buy my book -- out in a couple of weeks. Until then, however, you can download them off my site www.drsimpson.com the annual lab forms are there. Good luck.

<jewel> When is it safe to go to a fitness center after surgery?

<Dr. Simpson> Never, I avoid those places. Most surgeons don't want you lifting anything more than ten pounds to twenty pounds for six weeks to six months after surgery. Check with your surgeon to see what his/her requirements are.

<dee> Which WLS is the most common one? Because all I know is that I'm having RNY-Gastric Bypass-Lap.

<Dr. Simpson> RNY is the most common. But why be common?

<Tater-tot> What is the impact of WLS on Sex drive..... will I still have the same high drive, or will it plummit?

<Dr. Simpson> That is a very good question, and one which has a complicated answer involved. Most of my patients note that early on the sex drive decreases, and that is normal after you have surgery and a lot of your energy is spent on trying to heal your body. Then, as you lose weight, some notice they feel good about themselves and their drive increases. This is a dangerous time, because we don't want pregnancy for the first two years after surgery. Not everyone acts the same way, however.

<Carla> I had WLS back in 1976 and that was back when the pouch was made larger then they do now and in 2000 had intestines done only. Problem is I have kept off 125 pounds but still 100 pounds overweight. What can I do?

<Dr. Simpson> Without knowing what your anatomy is, it is difficult to tell what should be done -- if anything. Generally we think that two good procedures is about what our limit is for patients, because the increasing risk of procedures. However, sometimes there is an anatomical reason for the lack of loss of excess weight. Again, I think that the best thing to do for anyone contemplating a revision is to learn what they eat, how much they eat, and keep a journal of it, then you can calculate your daily caloric intake. If you get a healthwear band you can calculate the output also, which is helpful, since their site will also help you do stuff.

<Elaine> I am 22 months out and down 148 lbs. I am constantly craving crunchy carbs i.e (cereal, crackers) how do I overcome these cravings?

<Dr. Simpson> There is nothing wrong with carbs --- oh my, did I hear a few jeers???? Carbs are good for you, but like fat, or protein, or alcohol, only a certain amount. Many patients are under the mistaken belief that carbs are bad, and while they do contribute to weight gain, they are not alone. If you want crunchy stuff, then get something that has a lower glycemic index. What is the glycemic index? That can be seen on my website www.drsimpson.com

<debra hixson> i have not had surgery yet is there a diet i should be on before surgery?

<Dr. Simpson> Some patients benefit from a diet before surgery and some surgeons require that patients lose weight before surgery to see if they are compliant...Doesn't always work that way. What we don't want is to have you binge before surgery because that leads to an enlarged liver which can make our surgery more difficult for both patient and surgeon.

<Linda> How big can the pouch stretch?

<Dr. Simpson> The size of Texas. Not Alaska, just Texas. We expect that after a year they will be 8 to ten ounces and that will not interfere with weight loss.

<Bill> Once the stomach is fixed via lap band, my personal preference, does the brain follow and are the hunger pangs satisfied?

<Dr. Simpson> We try not to hook the brain into the lap band when we do surgery. If we do then we have gone a bit too far in our dissection. The lap band works because the nerves --or the sensation of fullness -- rest in the upper stomach and when that part gets full, your brain gets the signal that it is time to stop eating or start vomiting. Most of us choose to stop eating, except Aunt Mitilda -- but she is special.

<Andrea> what are the best types of foods to eat after surgery?

<Dr. Simpson> Protein, low glycemic index carbohydrates -- avoid alcohol, fat, and processed foods. Avoid restaurants that I go to, because they are bad.

<Kelsey> When can we start eating more solid foods? Do you recommend no carbs ever? Or more everything in moderation?

<Dr. Simpson> I recommend that your carbohydrates have a low glycemic index, and that you advance those as your weight loss continues (see the website or my book). Solid foods are individual -- for some it is done in the hospital before discharge, for others it is six weeks later, all surgeons have their own program. Mine, of course is best.

<brenda> What is the name of your book?

<Dr. Simpson> Weight Loss Surgery: A Lighter Look At A Heavy Subject --- to be available in the next month. On sale everywhere by the end of summer, at the obesityhelp.com bookstore in June, and at Dr. Simpson's website in Mid May.

<plateautoosn> Dr. was the fact that I vomited a lot convey the reason for my early plateau?

<Dr. Simpson> No, you vomited a lot because you over ate your stomach, and if you over eat you will vomit, and if you do that a lot and don't vomit you can lose the advantage of the surgery, and not get as much out of it as you can.

<Linda> What is the stoma?

<Dr. Simpson> The stoma is the opening between the stomach and the intestine (in the case of RNY) or the upper and lower stomach (Lap band). The size of that stoma will determine how fast food leaves that pouch and the faster it leaves the pouch, then the faster you get hungry. Think of it like an hourglass... When you have a larger opening between the top and bottom the hourglass will be a half hour glass.... or take less time...that opening is the stoma. The smaller the stoma, the longer it takes food to leave. Obviously, if it is too small you will NEVER be able to eat and you will lose a lot of weight, but not a great ultimate outcome.

<NoName> If I need to take a antibiotic for claymdia, will the iv's i'm givin in hosp battle the possibility that I have that as well?

<Dr. Simpson> Probably not -- you should get that treated first, then get surgery done.

<jacqueline> hello, besides drinking water, what else can one do to prevent saggy skin?

<Dr. Simpson> Ah, if your skin is stretched, it is stretched and a plastic surgeon's knife will overcome it really well. Otherwise, exercise for tone will help a lot.

<Karen S.> What is an ml? I can eat ANYTHING-especially sweets:( Surgeon was horrible-probably have a large pouch - he was new at the "game" - I am very active.

<Dr. Simpson> There are 30 ml to one ounce. There are eight ounces to a cup. There are -- etc. Well, if you eat sugar that is not your surgeon's fault. Sugar is what you eat. I doubt that he/she is forcing you to eat sugar. We want you to be able to eat anything -- but we want you to eat a limited amount of it.

<plateautoosn> Do you do dystal bypasses to correct an underaccomplished rny?

<Dr. Simpson> Under accomplished RNY -- I wonder what that means. I will guess at it.... If you have a RNY, then you should have a tool to lose weight. If you need a distal bypass, then you take some additional risk, however, that is not always a bad thing...For my patients, I think the first thing is to get them to eat right, and to exercise, and then we talk about revision. Most of the time the revision needed is to decrease stomach size, and sometimes it is to convert to a longer limb RNY.

<Kelsey> Which surgery would you chose to do on your wife, sister, mother, or daughter..if they were canidates?

<Dr. Simpson> My wife is the size of a small Ethiopian, and probably needs to eat a few steaks. I don't have a sister, but if she was like me she would need a lap band. My mother -- God bless her, will be fine as long as she can keep active with her garden and her doggie and my dad (who is probably chasing her around the house right now) and I am not blessed with children, but if I had a daughter she would be chained up in a tower so that she would avoid meeting anyone like her father.

<Tater-tot> Will my Steatorehha be affected by my RNY? My Steatoreeha was from Lap Choly as a 16 year old (now 25)

<Dr. Simpson> Sometimes that fat malabsorption can be made worse with the rearrangement of the gut, so you probably do not want to have a distal bypass as that might make you a bit incontinent with looser stools than you have now.

<gail reynolds> Are the mortality statistics improving? Last I heard it is still 1 in 200. That is too high for me.

<Dr. Simpson> The mortality statistics vary from 1 in 50 to 1 in 200 for RNY, DS, and VBG. For the lap band it is about one in ten thousand.

<Patty> Have you ever done the surgery on a patient with Hepatitis C?

<Dr. Simpson> They are lower for people who do more than 100 cases a year. I have done surgery on patients with hepatitis C, not a problem.

<lorri> I'm 6 weeks out and i wonder when i will feel "normal again physically" ?

<Dr. Simpson> In another six weeks you will forget you had surgery. The first 12 weeks suck.

<Nancy> my husband had the gastric by pass surgery about 4 years ago, and he has had one abdominal hernia repair since then. He is again having to have another hernia (same) repair, and he also wondered about having his surgery "touched up", as he is able to eat normal amounts of food, and has to seriously watch what he eats or he will gain his weight back. He lost 85 pounds in total, but it is a constant battle for him to keep it down. He fluxes all the time from 205 to 225.

<Dr. Simpson> Having a revision at that weight is not an indication for surgery. Obesity is a lifelong disease, which we all battle. I have a very good friend who has a BMI of 22 and always thinks about what she eats. My best friend from college (we did have college back then) still works out four times a week and when we go to dinner he worries over every choice. That is just normal.

<angel> why do we need so much protein?

<Dr. Simpson> You need protein because it helps you heal, and it is not that you need more protein. You simply need enough protein, and if you have a distal bypass you need more because you have less ability to absorb the protein, and because of that, you have to eat more to make up for it. That is why. Simple really. You just need enough.

<Kari> I have not lost any weight or inches for 7 weeks, someone said I'm not taking in enough calories vs what I'm burning. Could this be true? How can I start losing again?

<Dr. Simpson> You can start losing again with several methods --- For example: Walk more-- if you walk, then you can lose more weight, so walk. If you eat less you will lose more weight, so if you can, change what you eat. In the last issue of the ObesityHelp Magazine I went through a whole bunch of tips.

<Dr. Simpson> And the last question is??????

<Donna> How long after having open RNY can one get in a swimming pool?

<Dr. Simpson> Three weeks, unless you have a problem. Then it might be more.

<Dr. Simpson> Thank you everyone for a nice time, and I hope that you learned something or were entertained.

<**MODERATOR**> Thank you for joining us for chat tonight. Please visit Dr. Simpson's website at http://www.drsimpson.com/ for more information.