August 20, 2004

<Moderator> Welcome to tonight's chat with Dr. Simpson. Chat starts at 4pm EST/7pm EST. Please type out your questions and hit enter. We will see them and present them to Dr Simpson at the time of chat in the order we receive them. Thank you!

<IndyBob> My surgery is still over 2 months away (Nov 5) and I won't see my surgeon until Oct 12. I'm just wondering if you have any advice on what I should be doing in preparation during this **dreadful** waiting period?

<Dr. Simpson> Well Indybob -- I would suggest that you stay away from race cars for a bit but Indianapolis is a great city with a great device from healthwear.com which you can put on your arm and measure your intake and output. Here is some simple advice: start a walking program -- unless you have bad joints in which case get a pool that will let you do some water aerobics. Why? Because people will see this obese individual who will, over the course of the next, while lose weight -- then really start but the real reason is that you will feel better and the weight you lose now will NEVER come back. So -- start to walk -- walk, walk, and then walk again, by the way --- there is an entire section about this in my book (shameless plug) and since I get $1.67 for a book royalty, if you could buy a million copies then I could move to the Mexican coast and ruin my liver. Good luck with your surgery.

<gloria> Hello, I had banding in December, And it had to be removed due to internal swelling. I am told there is a larger band now, but my surgeon says I am not a candidate, due to scar tissue? He did put me on the HMR diet and said at 100 pound loss he will do open RNY, I am thinking of a second opinion, I much prefer the band, thank you Gloria

<Dr. Simpson> The band is a great option and once the band is removed it can be replaced. However, not every surgeon is comfortable with that type of redo surgery. There is a new 11 cm band which is available that you can use so I think that this would be a great option for you instead of the RNY. Good luck. Oh -- and walk.

<harry> I had an RNY 20 months ago. I did very well with weight loss going from 415 - 178 But I had terrible reflux all the time. I didn't get an answer or relief from the original surgeon, so I went for a second opinion. This surgeon said he knew what was wrong (from ct scans) and could repair it. After surgery, he told me it was a mess, that he removed the pouch, half my stomach, and 2 feet of intestine. He said that my bowel was now connected directly to my esophagus. I no longer have any refl but I'm always hungry, and can eat Much more than before. I'm worried about re-gaining weight.

<Dr. Simpson> Yes with that configuration you can gain a lot of weight it is difficult to determine how he really hooked you up but it is clear that there is not a feeling of satiety and people who have no stomach -- which is kind of like you are can gain weight, although they usually do not gain weight at all. My sense is that you will probably not gain weight -- but will lose for a while. However, you will now find yourself mortal like the rest of us and in fact all of us. Diet and exercise is something that you will have to do forever of course, if you are looking for some great recipes they are on my website www.drsimpson.com but I think you will be fine. Good luck.

<sabrina click> when having a lap RNY, do they deflate your lungs?

<Dr. Simpson> Lungs are not deflated at all in fact you still are breathing, or the anesthesiologist and his machine are assisting you because it is kind of bad when patients stop breathing. One of the downfalls of surgery -- we have to keep the patient alive when working on cars we can simply turn them off . Patients don't do well when we turn them off.

<IndyBob> It's my understanding that the surgeon likes to have patients stop taking certain medications prior to surgery. I'm wondering if this includes allergy medications (Allegra, Singulair)

<Dr. Simpson> Typically not -- and -- because I still have not received my $1.67 from you -- in my book is a list of the common medicines we like you to stop and when but they are like this: clearly stop aspirin and other types a week before surgery, stop lipitor and anti cholesterol meds a week before surgery, stop hormones two weeks to a month before surgery, stop donuts a week before surgery, and some things like vitamin E, St. John's wart, stop a week before, the allergy medicines are not a problem -- aaaaaacheeew.

<adrian> For some one with ibs would the rny be a better alternative to the ds?

<Dr. Simpson> Neither one is contraindicated in irritable bowel syndrome. Neither one should be done with inflammatory bowel disease (IBD), Crohn's and Ulcerative colitis. For that we would recommend the lap band but many with IBS do a bit better after surgery --- although I have a couple of patients who would disagree with me but hey -- good luck.

<Pam> Hi Dr. Simpson, Do you perform Lap Bands? If so what are your feelings toward it?

<Dr. Simpson> They feel nice and soft. I do lap bands and the latest data about lap bands show that they are every bit as effective as the RNY and in fact after three years they have continued weight loss where the RNY and the DS do not. The early studies done did not show this result and in fact, showed poor results, but it turns out that the doctors who did those studies were not well trained and did not follow their patients or provide the follow up that their patients needed. One of my next books is just about the lap band because the new data is pretty exciting and I like writing books.

<Pearl> dr simpson ...I'M 15 DAYS POST OP AND MY POUCH IS VERY PAINFUL! EVEN WHEN SIPPING WATER

<Dr. Simpson> Some find after they have surgery the pouch is painful with hot or with cold water. The inflammation of the pouch is called pouchitis for which we recommend some Pepcid Complete which is a chewable form of Pepcid (if you have no allergies to it) and has some Tums like effect also take it twice a day and if it continues to hurt you might need to see your surgeon. My pouch hurts right now because I need more ice cream.

<RAC> Doctor I am a 60 year old male, my weight is +/- 400 lbs. I have been a smoker for 45 years. My question is do you think my age is a problem? and also the smoking? I'm sure you will say yes on the smoking. So, how long do you have to not smoke before it would not be a problem with having surgery?

<Dr. Simpson> We, like most physicians, have patients stop smoking for a month before surgery and we even test nicotine levels (the devil you say) I have done patients as young as 68 years and they have done quite well. One of my favorite patients just died after having surgery a couple of years ago -- from a stroke.

<Angels4unme> I'm 13 months PO Lap RNY and my iron is low. I'm told to take a OTC supplement what mg would that be?

<Dr. Simpson> For iron -- one rusty nail a day otherwise two tablets of ferrous sulfate per day which is over the counter, sometimes you need a prescription for some of the other medications like chromagen forte.

<gloria> thank you, my surgeon says, he will not do the band again. I have a umbilical hernia, and he will not fix it until I have the RNY, do you recommend a Hospital or MD that might re do this banding?

<Dr. Simpson> It all depends on where you live. You can go to the inamed website and see who does the band in your area www.inamed.com

<lee> my whole family are drs and they are concerned incase of emergency- i won't wear a bracelet, is a card available

<Dr. Simpson> There are various cards and bracelets which are available some like to have the ones made special by Tiffany but honestly -- those things are not needed.

<lynnie owen> Dr. Simpson... where are you located?

<Dr. Simpson> Phoenix Arizona

<Moderator> Dr. Terry Simpson, Arizona Bariatric Center Website: http://www.drsimpson.com/ Phone: 602-234-8995 Fax: 602-230-8344

<Pearl> DR SIMPSON ... WHAT ARE THE SYMPTOMS OF STRICTURES?

<Dr. Simpson> Vomiting vomiting then throwing up food and keep throwing it up and cannot keep anything down, a great way to lose weight -- but doesn't work out too well.

<manda davis> If you go on a two wk diet to shrink the liver and you are doin 40 carbs a day but you dont lose any wt will your liver still shrink due to the low carb?

<Dr. Simpson> The liver will shrink, and should shrink on a high protein, high fat diet - low carb ----- keep on it-- Southbeach is the best.

<lee> i need my neck and tummy done does your office do plastics?

<Dr. Simpson> We do not do plastics at all, in fact the only plastic I do is when I am reconstructing hind parts. Just kidding -- there are a lot of good plastic surgeons around.

<seth> how much protein should we get in at 6 months post op i started at 400 pounds

<Dr. Simpson> That is a complex answer, which has a table which is in my book. It depends on the length of your common channel and the type of surgery you have and how tall that you are. We calculate all of those things in and come up with a number which is between 50 and 100 grams per day. I should put that table in my website -- and probably will after a bit it is NOT dependent on the weight from which you start. Protein has calories, and you can gain weight with protein. In fact, my son -- who has lost about 450 lbs was at a standstill for a while and started losing again when we got him off the high protein shakes and now he is fit, trim, and handsome.

<CROW -450#> ty ty

<Dr. Simpson> Course, he takes after me

<Pam> DR SIMPSON? DO ALL SURGEONS WANT YOU TO SEE DIETITIAN,PSYCHOLOGIST AND GET LUNG X-RAYS?

<Dr. Simpson> There are some things that we all require. Psychologist is not one of them, some find that it is helpful to go see them. We all require some x rays and some blood work, which is routine for any surgery. We require that our patients see a shrink, see our nutritionist and we have some baseline lab tests, although some patients need more tests. I think seeing a shrink is helpful because after surgery you may need to have someone who is not a family member to be a support for you if you are already seeing a shrink, then that is fine because obesity has two components one is your head and one is your gut we fix the gut, but not your head. My mom says that my head just isn't screwed on right but lets not go there.

<sabrina click> How much of the small intestines are usually bypassed?

<Dr. Simpson> In a lap band -- none. IN a RNY anywhere from 2 feet to 12 feet. The bypassed part is not seen by food and therefore does not absorb food. This seems to aid in the weight loss, however the majority of weight loss comes from the stomach restriction more than anything else.

<peg> If I am at 9 mo post op with a BMI of 20, taking enzymes...how much longer til I can expect to stop losing weight?

<Dr. Simpson> Well, peg, that is a great weight loss and the answer is simple. When you reach enough calories to maintain yourself that is where you will plateau. The body is a simple machine, really calories in and calories out --- any excess on either side will lead to either weight loss or weight gain. The only way to determine this is to analyze you with some machines to determine what your calorie expenditure is per day and to also see what you are eating. A great device to do that is with the healthwear band www.healthwear.com which will determine those things with your input it will also help you determine if you malabsorb any amount of food also.

<shelly> had surgery 4/26 and worried that the only thing I can tolerate is high fat foods such as peanuts and cheese.is it ok?

<Dr. Simpson> You can tolerate more than that. We think you should be able to eat a wide variety of foods, including some complex carbohydrates as well as other proteins, fats, and so forth. High fat foods are not a good thing.

<karie> I am 8 months post op-what is the recommend daily vitamin intake. I hear different things all the time. My doc said 1 pre-natal vitamin a day is fine and I have good labs.

<Dr. Simpson> If you have good labs then one vitamin a day is all you should need, more is not better, more can be worse in fact -- but keep checking your labs.

<Angela Harris> I would like to know if you can eat beef that is tender when you're 3 weeks & 2 days out from surgery

<Dr. Simpson> It depends on what surgery you had -- what your surgeon's program is and generally the answer is NO -- however, there are exceptions to all the rules. If you take a bit and it does not up set you then you are lucky. One of my patients -- Tammy of the caste iron stomach --- ate beef tips before she left the hospital after a duodenal switch. She did great, by the way -- keeping in protein without a problem and is now riding horses in the outback of Arizona.

<Robin/OH> I have gained 20 lbs. back...3 years out...no matter what i do, don't seem to take it off...extra water, reduction of intake, help me! Do things like metabolite or green tea tabs help lose weight post op?

<Dr. Simpson> Metabolite and green tea help you lose weight by keeping your wallet lighter.

<Angela Harris> I would like to know when can you eat popcorn after having gastric bypass.

<Dr. Simpson> In terms of taking those last 20 lbs off that is the struggle that we all have and it is simply diet and exercise although you have an advantage that we mere mortals do not, you have a smaller stomach. There is a saying that you cannot manage what you do not measure so what we suggest to our patients, and in some cases require of our patients, is that they measure what they eat and that they increase their activity level. The healthwear.com band is a great way to do this, as are using devices like some of the watches that have pedometers and heart rate monitors with them and fitday.com is also another resource that we recommend.

<IndyBob> OK. I'm convinced... I'll buy the book.... Just one more question for now, then I'll consult the book. Are there any general guidelines on how much of the small intestine is bypassed in RNY and how you determine whether it will be proximal, medial, or distal?

<Dr. Simpson> Yes -- which is about 40 pages worth of stuff --- however it is the stomach restriction more than anything else that is responsible for weight loss, it is not the bypassed intestine. Malabsorption is not benign, and can cause problems. So we are careful with that.

<StephanieNC> Which surgery do you think is the safest and most effective in losing weight??

<Dr. Simpson> Safe and effective -- sounds like a commercial for some pill. The safest is clearly the lap band, the most effective surgery is the surgery that is combined with aftercare. It is the follow up and the attention to detail that will help you the most with your aftercare and that will be the secret. Weight loss surgery still means you have to diet and watch what you eat and you have to exercise, there is no way to get around it.

<Pam> Have you had problems with UHC epo paying for the lap band?

<Dr. Simpson> United Health Care has paid for the lap band without a problem.

<StephanieNC> Do you lose weight as fast with the lap band as with the RNY?

<Dr. Simpson> You lose weight more quickly when you pay attention to what you eat and if you start a program of walking. All results are individual, and every individual can have different results. I have had patients who have lost a lot of weight in a year, or in a few years. We do a lot of duodenal switch operations, which is thought to be the most effective operation for weight loss. However, we have people who lose all their excess weight in a year with the lap band and those who still have those last 30 lbs after a DS-- it is up to the individual and what they do. So statistics are just that, they are not what any individual will do. We have had patients with the RNY who have only lost 40 lbs and with lap band who lose 40 lbs in two months. So -- again -- you cannot manage what you do not measure -- so we encourage and demand patients measure what they eat and what they do.

<slz 10 days po> I am 10 days po and I ate for the first time yesterday. I didn't feel full after my 1 oz of cottage cheese. Is this normal?

<Dr. Simpson> Welcome to this side of the world and sometimes cottage cheese goes down quickly and doesn't leave you satisfied. Once you get to more solid food you will find yourself with less hunger pains than now. Good luck on your journey -- and start walking.

<Kerri> hello Dr. Simpson Im a post op 1 yr and wondering how long the weight loss will continue im down 132lbs.

<Dr. Simpson> Weight loss will continue until the calories you consume equal the calories that you use during the day. Sounds simple, but it is true and that is why we encourage people to measure what they eat and we encourage people to measure what they do. You can lose a lot of weight, or not much weight. I remember one patient who two weeks after a RNY called me because she was able to eat two cookies without dumping (which happens a lot) she didn't lose much after her surgery, however. If you want to lose, the answer is simple --- learn new foods, new habits, and start a great new habit of walking a lot.

<Arissa> I was wondering Dr., I weigh 285 (f) and I would like to avoid having the open RNY, how much do you suggest I lose so that I can have the lap RNY

<Dr. Simpson> It all depends on your surgeon, not on me -- as I am not your surgeon. Some surgeons will not do laparoscopic surgery until their patient has a BMI of 50 or less. For those of us who do the lap band we don't care what the bmi is -- cause we can do it all through the scope but, I think you should probably be fine to have your surgery done through a laparoscope. Good luck.

<Susan> what is the window of opportunity for weight loss i've been on a plateau for a month at a year out.

<Dr. Simpson> Your window is the rest of your life. There is weight loss from the surgery then you reach a permanent plateau where what you consume and what you use equalizes, and the only way to lose more is to diet more or to exercise more. Plateaus are more common after a year --- the lap band continues to lose after three years, the duodenal switch up to 18 months, and the RNY sometime between a year and a year and a half.

<S.FITZGERALD> My sister had this surgery done in April 2004 and she is still vomiting and cannot eat hardly at all. Most of the vomit is mucus, is that normal? She says she feels like she is fading away.

<Dr. Simpson> No, vomiting is not a normal thing at all and in fact, she should have that checked out. There are a lot of reasons to vomit -- and some of them are not so good. In fact the only good reason to vomit is if you have a squirrel in your throat. So your sister needs to see her surgeon.

<Dar in Pa> After losing 150# 3 years ago with open RNY, I would like to loose 20# more any suggestions?

<Dr. Simpson> Move more, eat less ----- Again, you cannot manage what you do not measure. You must record everything that you eat including the calories, and keep a record of your activity. Some devices, like the healthwear.com band do this, or some of the new timex watches will help but you have to do that in order to see where you are going, want to lose --- then you will need to see where you are and what you are doing.

<john> is there a difference in sexual desire post op normally?

<Dr. Simpson> There is usually a decrease in drive in the early post operative period, sometimes lasting for six months or more. Then something gets turned around and ----- wow ----- which is why we recommend patients use some method of birth control as we do not want to have children the first couple of years after surgery. If your drive does not return after six months we recommend you see a specialist to determine if there is some reason for the loss of drive although I tell my patients not to have sex for 17 years after surgery.

<SecondChance> Good evening Dr. Simpson...are support groups ideal for post or preop patients?

<Dr. Simpson> Support groups are great -- I love my patients and we have a good time in the support group. So they are good for pre op patients because you get an idea of what crazy things we are doing. They are great for post op patients because you can meet a lot of people who are going through or have gone through what you have.

<Pam> DO YOU RECOMMEND SURGERY FOR SOMEONE WHO IS 228PLDS. AND 5"3?

<Dr. Simpson> Close to needing surgery that is certain. For women, yes that probably is surgery territory. So that is something that you can do and check with your local BMI calculator. Which you can find on my website at www.drsimpson.com/bmi.php

<Melody> How do we know how to maintain w/o gaining? I am 5'3" and for the last month have fluctuated between 115 and 120

<Dr. Simpson> Well, this seems to be a theme today: the saying is: (class, pay attention here) you cannot manage what you do not measure. Ok, lets try that again: you cannot manage what you do not measure. No everyone in the audience say that out loud you in Cleveland -- I didn't hear you. You need to measure what you put in your mouth, everything and you need to calculate the calories that you use. That is a simple thing to do. A free website to help is www.fitday.com to measure calories used you can get a fancy device called a pedometer with the goal of 10,000 steps per day or one of those fancier watches and the cadillac of all is the device from healthwear. www.healthwear.com

<shelly> I have been having headaches recently. what should i do when tablets and pills are hard to get down? post op

<Dr. Simpson> Crush the tablets and put the powder with some splenda and a bit of water and swallow it.

<Dr. Simpson> Hey try this again: Everyone stand up come on stand up now jump. I know the knee hurts but jump now think about the walk you will take when we are done here and remember this phrase: YOU CANNOT MANAGE WHAT YOU DO NOT MEASURE weight loss surgery is a tool and as a tool you need to use it. It is not a passive tool, something that is done to you and then you can forget about it Weight loss surgery is ACTIVE and the more active you are --- the better you will feel, and the more weight you will lose.

<uban> is there a chance that wls might not work for some people? not enough will power?

<Dr. Simpson> Uban -- did you jump? I didn't see you jump. Weight loss surgery is partially about willpower, and many of you have more willpower than you know ---- if you have been on a diet, and lost weight, and suffered through that for a long time then you know you have willpower. The great thing is that surgery makes it so that it is easier to lose weight because your stomach is smaller and as a result it takes less to fill you up so you can consume less and enjoy a wide variety of foods of course foods that are densely packed with calories -- such as breads, pastas, and the like or dessert -- God I love ice cream ---- tend to put more calories in your system so -- we have another saying here walk, walk like a man going after his first date -- walk like a cop going to a donut shop -- walk like a bum seeing a bologna sandwich --walk until you can do a mile in 15 minutes and plan on doing three of those miles a day and when you are done walking walk some more.

<Melody> Dr. Simpson, I have had trouble with a persistent marginal ulcer on and off for the last year. My surgeon has indicated that he will have do go in and redo the surgery if the ulcer doesn't heal. Since I am below goal at 118 lbs, would this mean I would lose more weight?

<Dr. Simpson> No, it probably won't mean you will lose weight -- but if your ulcer has been there then it probably will need to be resected (surgerized) and removed in order to allow you to heal, and be good and normal. Then again, normal is something that the shrinks define and most shrinks who I know are NOT normal.

<Ashli@4wks Post op> I am 4 wks post lap rny and am throwing up with every seafood thing i eat....is it becuase it is too soon for seafood, or I just wont be able to eat it anymore?

<Dr. Simpson> Some foods are simply harder to tolerate than others and for you that might be seafood --- if there are other foods which you can tolerate then go to those. If you cannot tolerate any foods then you need to see your surgeon and you may need some other work done. Good luck.

<Moderator> And the last question goes too.....

<hopeful> why would my doctor take me completly off startches 2 months prior to surgery?

<Dr. Simpson> Starch in my shirt is nice because it keeps the creases -- however it wears the shirt out. Ok-- the reason is that your liver can accumulate those and become quite fatty and a fatty liver can cause a lot of problems so, many surgeons will put patients on a carb free diet.

<Dr. Simpson> I want to dedicate this chat to a patient of mine who died this last week. He had a duodenal switch over a year ago and had lost a lot of weight. He was 64 and died of a stroke. His name was Mike - and I hope you all pray for his family. He had a great twinkle in his eye and I also want to dedicate this to my cat who was run over by a car on Wednesday night and died. Her name was Jinx. Thank you all and good night.

<Moderator> Thank you very much Dr. Simpson , We enjoy your chats every week. We all thank you and have a great weekend.

<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 (Fax: 602-230-8344) to schedule a consult. You can get his book at www.obesitydr.com.