May 7, 2004

<**Moderator**> Hello and thank you for coming to tonight's chat with Dr. Simpson. Our chat will begin at 4pm pst and go till 5pm PST. Please enter your questions and they will be posted and answered in the order received. Thanks again for joining us.

<marsha/il/11mon-143> Hello, i am a 11 month post op and i feel like i am starving and always catch myself eating!! Is there any ideas you could give that might help me

<Dr. Simpson> Don't starve so much. Oh, sorry, I thought this was the anorexia chatroom you have to do the following: first do not skip meals, three meals a day, drink water one and a half our before you eat, a lot of water we call it water loading --- and -- plan your snacks. No random snacks, plan them during the day. A midmorning and a midafternoon snack. Protein based, not junk. Simple stuff. Keep going, good luck

<Marsha/IL/11mon-143> How many calories should i be getting a day

<Dr. Simpson> Well at 11 months it isn't so much about calories, as about what you eat. Certainly you want to keep about 500 calories a day below your basal rate, which depends on your goal, and where you are from the goal. If you are below goal at 11 months, than 500 calories. So, we are talking between 900 and 1200 depending.

<Dr. Simpson> For those in the room who are wondering, we just received the first printings of my new book. Weight Loss Surgery: a lighter look at a heavy subject, now on sale through the obesityhelp.com bookstore

<amyh> My question is concerning treatment for fistulas that connect the new pouch to the remnant stomach after rny

<Dr. Simpson> There are no non surgical approaches to this yet-- unless the fistula is very small, then there are some gastroenterologists who can close it with an endosuture, but those would have to be very advanced folks, not commonly found if it is small, then don't stress it, and it will remain open, and be a pain, and someday you will need to have it closed, if it becomes large and a problem. Which is revision surgery, and not as fun or easy as the first surgery, but it might be needed. Good luck.

<kathleen g> Dr. Simpson: 10 weeks out open-RNY and can't seem to eat enough. Should I force it? Thanks

<Dr. Simpson> No do not ever force food-- if you force food then what will happen is a staple line blow out, a fistula, a pouch enlargement, or a stoma enlargement, all of which are not good. You should be on some solid foods by now, avoid the puree stuff and the soup and only go with some good solid stuff. Like fish, or chicken for the stock and bulk of the meal or some hearty vegetables... Lentils. See your surgeon to make certain that nothing is bothering you.

<DingyBlondOKC> hello to everyone. post op 3 months out.. i was told if you drink with meals it washes all the food out of ur pouch.. and was curious if that was a true fact

<Dr. Simpson> A true fact... hmmmmm if you drink or gulp with meals you can wash it down, but most patients sip with meals and do just fine, in fact we say unlimited water or liquid 90 minutes out, and that doesn't do it. The key is to NOT GULP all of which is nicely covered in ..... THE BOOK (shameless self promotion here).

<A.Hoffses> What is the name of your book?

<Dr. Simpson> Weight Loss Surgery: A lighter look at a heavy subject, currently only available in two places: one is the obesityhelp.com bookstore and the other is www.obesitydr.com

<Anna> When do we stop malabsorbing after RNY?

<Dr. Simpson> Technically, you do not malabsorb, you simply have bypassed an area of gut and that area is not available for absorption until some surgeon -- handsome one like yours truly -- reverses you, however...you do have to know that your small bowel does accommodate: meaning, that it will absorb food better after a couple of years than it does initially, to make up for the lost length...which is unlike men, who cannot make up for lost length.

<michelle> hi dr simpson, i am almost four months out and i was wondering when can i drink diet soda?

<Dr. Simpson> Sunday

<Kalee> Hello. Can you tell me what percentage of excess body weight is lost with the lap band and what percentage with the RNY?

<Dr. Simpson> You are asking for a statistic, and you are not a statistic. Here are some for you however: early on the RNY out paces the Lap band in the first year or two, but by the third year the lap band not only catches up but starts to outpace the RNY, and recent studies show that it can continue to have a slow but steady weight loss over time, up to a certain point, after all we don't like a BMI of 16.

<Rita> I am about 3 mos post op and having problems with vomiting. Anything I eat I throw back up...what could be the problem

<Dr. Simpson> There are a lot of things which can be the problem and you need to be evaluated by your surgeon and have endoscopy by a gastroenterologist. You could have some scar tissue blocking the outlet or you could have an ulcer or some other things, or you could be not chewing your food. So, go see the doctor please. thanks

<Kelly> I can't wait to read your book. I have heard such good things about you. Can you tell me what is the difference betwen the DS surgery and the regular rny?

<Dr. Simpson> About three thousand dollars. Oh, sorry. Yes, actually there are a lot of diagrams on this website and my website www.drsimpson.com which will show you the difference between the two operations. Essentially the DS does not have a stoma between the stomach and intestine but leaves the pylorus intact which works to keep things in longer so you cannot force things through and the DS has a longer malabsorptive component, although it is still only moderate

<suzan> Good Evening...I would like to know how important is it to count carbs, I have heard that 20grams is what we should be having

<Dr. Simpson> 20 grams per meal, however carbs are not always to be counted in that manner, the thing that is important is how fast the carbs break down inside of your body. For example, donuts breakdown fast, an apple does not, so they have the same amount of carbs, but clearly with the apple you will feel full longer and your blood sugar will not rise as fast and you will not store a lot of that type of carb as fat, but the donut goes to the thigh -- or, in my case to my rather slim wasteline

<Kathleen g> Dr. Simpson: What is your take on bottled water vs. tap water? I understand you have opinions about still water. Thanks.

<Dr. Simpson> Still water runs deep, very good question and there is a simple answer here. First, bottled water does not have the same health regulations as tap water, so with tap water you can actually get some bacteria contamination called Camplybactor jejuni, which one of my patients had recently with tap water you will probably not get that as it is treated so, bottled water does have a few more germs, if however, you live in Phoenix where the tap water is not drinkable by most humans and my dogs rarely drink it, then you need bottled water or something... and I prefer and ask my patients to drink a lightly carbonated water, such aspelligrino, or perrier, which won't stretch anything and it has far fewer germs than still water... so, sparking things are good. Diamonds, champagne, and sparkling water.

<Melissa> I was told that my ins excludes this surgery. What other options to I have to fight them?

<Dr. Simpson> If your policy specifically wexcludes it, then have it reviewed by an attorney who specializes in those things, such as walter lindstrom at www.obesitylaw.com. However, the best option -- get some financing and pay for it, you will find it to be a great investment better than a car

<Michael> Being 6'4 and 486 lbs what is my goal weight after surgery?

<Dr. Simpson> To weight less than what you do now. About 220 lbs would be great for you, although we like your weight to be with a BMI of 22 to 24, so go play with it a bit and see to get there you have to walk then walk some more and walk more, help the surgeons along: walk.

<Criselda> I have heard more and more about surgery in Mexico...what do you think about this?

<Dr. Simpson> I have a very good friend who is an outstanding surgeon in Mexico, and that is a great option, unless of course you have a problem, and then you find yourself in a hospital which is no equipped to deal with your new problem be that a heart attack, pulmonary embolism, or the like and while we don't like to think that can happen to us, the extra you pay to have surgery in the US is insurance on the best healthcare system in the world being instantly available to you in case and it depends on how much you want to risk your life, or how many dollars that is worth it to you but trust me, my friend, Dr. Ortiz, is one of the finest laparoscopic surgeons in the world.

<Louise> What is the oldest that surgeons will perform surgeron on someone? I am 71 and overweight and need to lose weight.

<Dr. Simpson> I did a lap band on someone who was 69, but that was a stretch. So it depends on the patient and a lot of factors, and every surgeon is different in this regard but, not too late to diet.

<Ticks> I have recently heard a story about the band migrating into the stomach wall. Is this something out of the ordinary or is it a factor to remember as part of the Lapband things that could go wrong?

<Dr. Simpson> There is a less than two per cent incidence of band erosion into the stomach and that is real, that is one of the risks of the lap band, and something you have to keep in mind when you consider your decision to have or not to have a lap band surgery performed. However, erosion risk is still less than leak risk, and much less deadly. So, that should also go into the equation. good luck.

<Kat> I have acute erosions of the stomach. We were hoping this surgery would help, but the insurance has denied. Where do I go from here.

<Dr. Simpson> Erosions of the stomach have nothing to do with obesity, and everything to do with a lot of other things in terms of insurance, that is a separate matter, they either approve or disapprove based on criteria presented and erosions are not a criteria for weight loss surgery so, instead, I think you need to determine criteria and see if you fit into them. Erosions are not a criteria on anyone's list. When I hear patients talk about risks of surgery I am almost shocked because I wonder, do their surgeons really tell them, and I know that they do, so I am wondering why some patients do not seem to feel they hear these things. An interesting question to think about. We make our patients sign a lot of stuff, and we tell them, but I am sometimes surprised when I hear them saying to one another -- Oh, I didn't know that...alas, there is a lot of information to learn about weight loss surgery, and it cannot all be absorbed with a few doctor visits. I had a patient who is a genius -- belongs to Mensa, and his girlfriend is also, they came to all our seminars, talks, classes, and pre op visits. Both of them wrote down things, and often one would get what the other would not, so it is simply a lot of material to learn about weight loss surgery, which is one of the reasons that I wrote what was going to be a patient pamphlet and ended up being a 400 page book. So you can see and evaluate a lot of material for yourself.

<Alicia> Having had rny surgery three years ago, I find that I am not starting to gain weight. I think I need a revision, since I have not lost all my weight. I started out at 340lbs and I am 5-4. Would you recommend a revision to help me lose the rest of my weight?

<Dr. Simpson> Alicia, revisions are not a walk in the park, they have six times the risk of any surgery and if you are reasonably close to a normal BMI I doubt that is what you need, I often have patients who want a revision, go through classes and wear a band from www.healthwear.com which allows us to see what they expend in calories and what they eat, often times it is not necessary to have a revision, but instead have education about what to eat, and better choices to make.

<Beany in PA> Hi Doctor. Can you tell me what is the best way to get protein in? Protein drinks or protein from food? I am finding that it is hard for me to get my protein in by eating, since I cannot eat that much.

<Dr. Simpson> It is difficult to get protein in by eating, as early on it does not save enough room for other stuff however, protein first is a key, and you will heal faster the more protein that you do get in. Hence, I would recommend that you see how much you eat, and make protein first. If your physician determines that you do not have enough protein, and they do that by checking a pre-albumin level, then you might want to supplement with some modular protein drinks, such as a whey based protein, which is easy to take and more available to your system... I prefer elk steaks.

<Robin> Is there a book out that deals with lap band surgery?

<Dr. Simpson> Yes. Mine

<Beany in PA> Why do I have such bad gas? It is really bad to the point that I am afraid to go anywhere or to be around people.

<Dr. Simpson> There are a number of reasons for bad gas, and some solutions. Devrom tablets are a solution, and they have a website and an 800 number www.parthenoninc.com is their site two tables with meals should reduce malodor. Gas comes from two sources the first is swallowed air, but the second is undigested food that hits your colon and bacteria start to eat it, and some foods are worse than others... beans, for example (I know that is surprising isn't it).... for post op patients-- high fatty foods are a culprit as are gluten based products. So, check out what you are eating, get some Devrom, and don't light the match too close.

<Kat> I am 70lbs overwt and have Lupus, Fibromyalgia, GERD,HTN. The insurance say I have the med necessity, but not 100 overwt. Help

<Dr. Simpson> Well, you need to have the criteria which the insurance says if you want them to pay for it and if they won't pay for it, and you can convince a surgeon to band you, then that is a possibility, the weight loss will not make your lupus or fibromyalgia better. It may or may not help GERD and the high blood pressure will be helped with weight loss but it may not be totally helped. But you can still diet, and you can still exercise and you can get a band to see your calorie consumption and watch it carefully, which you would have to do with the surgery. www.healthwear.com but insurance companies, and some surgeons, have very strict criteria, and while you don't like it there is another thing you can do, begin medically supervised diets with your primary care doctor, so that the paperwork will begin and should you not lose enough weight and in fact gain weight, at least you will have a strong medical record that you tried, and that is very helpful to insurance companies.

<Brigitta> Dr. Simpson, what exactally is GERD?

<Dr. Simpson> Gastro esophageal reflux disease, commonly called "heartburn", however reflux disease is a disease where acid from the stomach bothers the lining of the esophagus, causing a burn, and sometimes causing ulcers, bleeding, or changes associated with cancer. It is treated most commonly with agents that reduce stomach acid, such as Protonix, Prevacid, Nexium, Pepcid, and the like and sometimes requires surgery to correct the problem, although now they are perfecting some endoscopic techniques to reduce the reflux from the stomach into the esophagus, including injection of certain substances into the esophagus.. to form a better barrier against reflux.

<Melissa> If I find that I have to self pay for my surgery, do all surgeons require that you pay up front, or do they have payment plans?

<Dr. Simpson> Surgeons are typically not loan officers, and so they will often have you referred to someone who is. So you borrow from the bank, not your surgeon, and that is probably better. After all, we surgeons do not want to be in the loan business, we are surgeons and we don't want to come after patients for a bad debt, so it is best if you borrow from a reputable places, or take out a home equity loan, and go from there then you can pay back the bank with your newer slim body.

<Kris Lynn> My BMI is 38, I have Diabetes and a strong family history on both sides of my family of diabetes and obesity. Since my number is only 38 will this possibly elimiate me by insurance.

<Dr. Simpson> Diabetes is considered a co morbidity by most insurance companies and should not be a problem for you, although some are more picky. Family history does not impress an insurance carrier, they don't know who your family is, they only know you so, I think that you probably will have a good case for getting the surgery done with a bmi of over 35 and diabetes.

<Teri> What are your feelings about military hospitals?

<Dr. Simpson> Some military hospitals like some community hospitals are great, and have some great surgeons with them, the president of the united states and all the senators go to military hospitals. So, there are some great surgeons who work in them, and they do some fine work.

<Tierney> I am about 17 weeks post op and moving to a soft diet. I am finding that I like the refried beans, but am not sure if they are good to be eating. What do you recommend for your patients on the soft diet.

<Dr. Simpson> At 17 weeks most of my patients are eating steak, not soft diet. Oh my, well, I won't sound off too much but if you have been on liquids until now -- wow. Anyway, beans are high in protein, and they also have a low glycemic index so they are not too bad. Refried beans, however have a higher glycemic index. At 17 weeks you should be on solid food in my opinion, but hey, my show.

<Ticks> if a person has a sweet tooth for cakes, pie etc - do you think that the Lapband is the right weight loss surgery for them?

<Dr. Simpson> There is no weight loss surgery that works for a sweet tooth, none and a sweet tooth can happen with any surgery. I do not believe that dumping is a good thing, in fact, most physicians will tell you dumping is a bad thing and it has no relation to weight loss. So, the lap band will work as well as other surgeries, but the sweet tooth needs to be modified. We think that there is nothing wrong with any food--- right now I am enjoying some smoked salmon. Which explains the sticky keyboard here but, you need to eat slightly differently , and less --- a thin mint is just that, it is thin, but the whole box is not thinning.

<Teri> what about those of us with wells??

<Dr. Simpson> If you like the taste of the water from the well, then that is fine. But it is always good to have water tested to make certain it does not need treatment of some sort. In my hometown, of Ketchikan, Alaska, we once sent some city water off for testing it came back with a slip that said, "Your horse has diabetes"

<WeepyingWillow> My husband is constantly asking when we can resume relations. I am only 3 weeks post op from open rouexeny what can I tell him?

<Dr. Simpson> I tell my patients to wait for 17 years why patients don't comply I will never know. You resume when you are comfortable and happy to and feel up to it. Like pregnancy, as soon as you are ready or, sooner.

<Vera> What vitamins do you suggest that your post op patients take, DR? My surgeon said flinstones, but I don't see how that can be suffiicent for an adult.

<Dr. Simpson> Flintstones contain 100 per cent of the RDA in most vitamins for adults. Of course, there is a nice chart of vitamins in the appendix of my book, so you can compare a few brands but Flintstones, one a day, or some other brands the important thing is to take them and have your blood tested at the six month mark, or earlier, to make certain that you don't have any problems.

<**Moderator**> ok and the last question of the evening goes to...

<dol> Excuse me...is it foolish to have gastric bypass by open method? My doctor will not perform the surgery laparoscopically becase of my BMI.

<Dr. Simpson> There is nothing foolish about open surgery, and some larger BMI requier that open surgery be done. So, that is quite normal. In fact, most weight loss surgery done in the US today is done via open surgery instead of laparoscopic, although more and more surgeons are doing the laparoscopic approach. So, good surgeon --- he will do that.

<**Moderator**> Thank you all for joining us this evening. To learn more about Dr. Simpson, please visit his website. http://www.drsimpson.com/, or call 602-234-8998 to schedule a consult.

<Dr. Simpson> The book: www.obesitydr.com. Thank you and good night.

<**Moderator**> Thanks Dr. Simpson. Thanks everyone for coming.