<**MODERATOR**> BARB YOU HAVE THE FIRST QUESTION TONIGHT:)

<Barb> I am going for my first appointment on tuesday. Have done alot of reading on this surgery. But am worried about my insurance co. What  kind of medical problems do they feel is urgent to approve surgery?

<Dr. Simpson(PHX> The first and most important thing is your BMI, which I assume you have calculated....

<Barb> yes it is 41

<Dr. Simpson(PHX> If your BMI is 40 without co-morbidities, then you qualify by NIH standards. The next is to see if your insurance company has an exclusion against weight loss surgery. If it does, you are best to get another insurance plan, or to contact obesitylaw.com. Otherwise, what you should gather together is a list of all diets, all the times you were under your primary doctors care and he was telling you to diet, and giving you prescriptions, or potions, or hypnosis. Every time you sweated with the oldies with a gay fellow.

<Barb> my insurance plan has a clause about one time weight loss and will pay a 1000.00

<Dr. Simpson(PHX> and once you have all that data together, make a time line, and it will be easier to approach your insurance with it. Good luck.

<**MODERATOR**> SUSAN5DAYS POSTOP YOU HAVE THE NEXT QUESTION:)

<Susan5DaysPostOP> Dr. Simpson, When can new post ops start on protein shakes?  I am sick of broth and jello :(

<Dr. Simpson(PHX> Five days, Susan, wow, welcome.

<Susan5DaysPostOP> Thank you Dr.

<Dr. Simpson(PHX> Protein shakes are something which can be started once you are off a CLEAR liquid diet. If they say you can be on liquids, then go for the shakes. I happen to like the road kill shake the best--- take some road kill put it in a blender, add water and it is a lot of protein, the fur kind of is hard to digest, but it is good fiber.

<Susan5DaysPostOP> My Upper GI is on Monday

<Dr. Simpson(PHX> When you get to regular liquids then you can go on the protein shakes. By the way, possum is the best to blenderize. Good luck.

<**MODERATOR**> CHERYLWRN YOU HAVE THE NEXT QUESTION PLEASE:)

<CherylWRN> Which procedure, DS or RNY, would you recommend to a 32 yo with BMI of 48 and numerous comorbids? Is lap still possible with 2 previous laps for endo/hyst?

<Dr. Simpson(PHX> Well, it would depend on what surgery your surgeon does. If your surgeon does only one thing, and not the other, then you have your answer. Not everyone has the opportunity to check with different surgeons and have multiple choices. If you do, you are lucky. Any one of those procedures will work. Most of the individuals who have made it to goal have made it with the RNY. Some of us do only RNY, some only do DS, but go with what they do best, and with who has the best follow up program. And find a surgeon you like and has a personality you can get a long with and someone who has a post operative program which is easy to follow and then you will be successful and live a thin life. Pass the ice cream. Good luck.

<**MODERATOR**> POCO YOU HAVE THE NEXT QUESTION:)

<Poco (5 wks po)> I have 2 wounds on my incision that just close but aren't healed. I see my dr Tues I don't think there infected but I am  worried I could get an ulcer..Is it safe to wait for Tues? theres no sign of any infection.....thank you

<Dr. Simpson(PHX> Sometimes incisions open at various spots, but are not infected. If there is drainage, or redness, or swelling, then you should call your physician. If they are open wounds, then you need to take care of them, and your surgeon may want you to take care of them in a specific way such as putting cream, lotion, or eye of newt on them.   So, you should give him/her a call and let them know, and they can get back to you.  Some surgeons, with open wounds , like putting patients on an antibiotic so, give them a call. Good luck. No swimming this weekend. Walk, though.

<**MODERATOR**> SANDY YOU HAVE THE NEXT QUESTION:)

<sandy> how so you get that last 20 pounds off, i am 17 mo. out i exersize about 3 tmes a week but i can take in about 1800 cals if i am not carfull, i do all my protien and low carb. but that last bit of weight is not comming off.

<Dr. Simpson(PHX> Sandy, this is almost too easy a question, but also the most frustration of all things for patients. It is those last twenty pounds that are there is no secret to this: first exercise four times a week, for 45 minutes at a time and make certain your heart is getting its rate up there. Next, watch your portions – not the calories, and make certain you are not drinking while you eat, otherwise, if you have an RNY, you will push the food through the pouch into the intestine. If you have a DS, then do drink, because it will take up some of the room and watch the carbs-- keep them to below 40 grams for the next while. That will do it. Here are foods to forget for those last twenty pounds, and only the last twenty pounds. Rice, potatoes, breads, and pasta--- you are in the final phase of a war, and you are winning..go the extra mile--- and you will do great. Good luck. Send me your pasta please.

<**MODERATOR**> NIKKI@GOAL YOU HAVE THE NEXT QUESTION:)

<Nikki@Goal> Doc S.. If you have had ulcer's before and you feel the symptoms again. Can you take reglan and protonix together?

<Dr. Simpson(PHX> Nikki, it is nice to see you here, and by the way, thank you for that very nice message the other day. Instead of medicating yourself with protonix and reglan (one is for decreasing acid, protonix) and the other is to facilitate gastric emptying (reglan), I think it is better to have someone look down there and see if that is what is going on, but if you have them, yes you can take them together without any problem at all. Hopefully you don't have an ulcer, just a pain in the gut from thinking about Halloween and if there are witches. There are by the way --- but JC has put her broom away again. Good luck

<**MODERATOR**> SCARLETT YOU HAVE THE NEXT QUESTION:)

<scarlett> Is there a way to know what fruits will make me dump?  Is is solely sugar content?  I'm 11 weeks and 54 pounds out!

<Dr. Simpson(PHX> Great result Scarlett, and frankly I don't give a ...wrong Scarlett. There is only one way to find out. Remember, fruits have high carbohydrates, and you can find out the specific number by checking with some of the protein and carb counting books. It is the sugars in the carbs. So if you dump-- avoid them, if you do not, then be careful because fruits can make you fat. Good luck.

<**MODERATOR**> BARB YOU HAVE THE NEXT QUESTION:)

<Barb> Doctor I am diabtic for 21 years, and had a heart attack 2 years ago also have GERD, and Spinal Stenois. Have been under doctors care for 3 years every month. Would those records be enough for the insurance co?????

<Dr. Simpson(PHX> Well, Barb, insurance companies don't always go by medical necessity. If it is a just company they would, but remember they are in the business of not spending money so, they may still want you to be under a doctor's supervised diet for a year, they may/....

<Barb> yes know that but in the long run wouldn't it save them money

<Dr. Simpson(PHX> want many things. Oh, they care about profits today, let tomorrow's board worry about tomorrow.  So, all insurance companies are getting a bit rougher these days, it is just to limit their exposure, that is all. But in a just world, you would qualify. Good luck.

<**MODERATOR**> JAMIE YOU HAVE THE NEXT QUESTION:)

<Jamie> Hi Dr... I am 11 days post op and hungry all the time.  Is it because of the liquid diet??? I had an open RNY.

<Dr. Simpson(PHX> Liquids go through the pouch very quickly, they don't fill the pouch up and as a result you will be hungry after them. Once you get to puree or solid you will feel full longer especially if you don't force foods down with liquids.

<Jamie> ok...sounds good. Thanks.

<Dr. Simpson(PHX> I have to tell a story, I have a very very good friend who had the RNY, we're at this wonderful restaurant, with an eight course meal and she ate a lot. How did she do it? Simple. Water after each course, washed down the pouch, and she had a lot of food..or was it wine?...anyway, the point is, if you want to defeat the RNY, drink water after you eat. If you want to feel full don't drink water or liquids for an hour after you have a meal, allow it to sit there and feel satisfied. Good luck.

<**MODERATOR**> CHRISTI YOU HAVE THE NEXT QUESTION:)

<christi> I have had cramping for the first time, been going to the bathroom alot, could it be caused from 3 milkduds?

<Dr. Simpson(PHX> Christi it does not take much sugar to dump. One sugar cube can take someone who has an otherwise normal day and turn it into a very bad time, with diarrhea, cramping, and not feeling well so, milk duds for you are bad. Do not eat them. You don't need them. They are not your friend, they are your enemy, now, your body is rejecting them. You should to. Send them to the Arizona Bariatric Center. Good luck. Feel better.

<**MODERATOR**> ELENA YOU HAVE THE NEXT QUESTION

<Elena> How is my favorite chardonnay processed now that I've had RNY? Is it true that it's harder on my liver now?? After I hit goal of  course.

<Dr. Simpson(PHX> It is absorbed much faster, and thus the alcohol gets to your liver a lot faster...on the other hand, while you will be easy to get drunk, you will get sober faster also, so that is a better side. There is a good theoretical question as to whether the toxins from alcohol in their degradation, hang around longer because you hit the liver with them so fast.

<Elena> ...so is it harder on my liver?

<Dr. Simpson(PHX> So, everything in moderation. We don't really know, we guess that might be the case, however.  So, buy very expensive Chardonay's, like Montrachet, so you are not tempted to drink too much and you should be fine. What I mean is that the alcohol hits the liver fast, so it breaks down fast.

<Elena> yes, i tis harder on my liver?

<Dr. Simpson(PHX> and the byproducts of the breakdown, one of which is harder on the liver, are more abundant so we THINK it might be harder on you, but cannot answer that with certainty== it is a theory. So drink in moderation, not in excess. A little would be ok. So drink the good stuff. Good luck. Salute.

<**MODERATOR**> JOANMIAMOR YOU HAVE THE NEXT QUESTION:)

<joanmiamor> yes i am 6 weeks post op and have a question about tummy tucks, breast lifts ive had problems with rashes in both areas and i also have back pain im on medicare and wonder if they pay for the tummy tuck, breast lift if medically nessicary

<Dr. Simpson(PHX> Sometimes they do, and sometimes they do not, generally with the rashes, and with photographs of them and treatment by a physician, it might be all that you need. They probably will not pay for the breast lift, although one never knows-- do one.....

<**MODERATOR**> ANTHONY REED YOU HAVE THE NEXT QUESTION

<AnthonyReed> i have been to several of these chats and find them very informative,I took your advice and I guess I walked 7 miles today,any suggestion for leg cramps

<Dr. Simpson(PHX> A nice hot bath.

<**MODERATOR**> MIZZOUTIGERS YOU HAVE THE NEXT QUESTION:)

<MizzouTigers> I'm 13 weeks post-op & I've never been sick or dumped...I've lost 78lbs in 16 weeks am I normal?

Dr. Simpson(PHX> only 60 per cent of people with RNY dump, and only 5 per cent with DS do..

<MizzouTigers> I can eat everything.

<Dr. Simpson(PHX> and only thirty per cent have bad vomiting, so it isn't unusual. Keep loosing, and thank your lucky stars.

<MizzouTigers> It's scary because it makes you wonder if the surgery was done right.

<Dr. Simpson(PHX> that you have not had to suffer. The surgery was done right because you are losing weight but if you want to vomit we can arrange that.

<**MODERATOR**> SUSAN 5 DAYS POSTOP YOU HAVE THE NEXT QUESTION:)

<Susan5DaysPostOP> Dr. It seems like my wound dressing is soaking up more than my drain? is that common? I have to change the dressing twice a day.

<Dr. Simpson(PHX> That is not common, and you should ask them to look at it as draining is not a thing for wounds to do so, call your surgeon. Good luck.

<**MODERATOR**> ANTHONYREED YOU HAVE THE NEXT QUESTION

<AnthonyReed> how is bmi figured,and what is a number that insurance would not usually say no too

<Dr. Simpson(PHX> it is determined by the height and the weight, and 35 with co morbidities and 40 without.

<AnthonyReed> do you know if there is a counter on this site

<Dr. Simpson(PHX> there is on this site.

<**MODERATOR**> LORI 5-29 YOU HAVE THE NEXT QUESTION:)

<lori 5-29 78pds> i started 272 i am 5 months out and lost 78pd how do i know if im on target

<Dr. Simpson(PHX> You are. Great result.

<lori 5-29 78pds> is there some percentage to figure

<Dr. Simpson(PHX> 10 per cent at six weeks. 10 lbs per month average

<**MODERATOR**> MIZZOUTIGERS YOU HAVE THE NEXT QUESTION PLEASE:)

<MizzouTigers> I had an open RNY with a section of my small intestine removed...what is that officially called?

<Dr. Simpson(PHX> RNY

<MizzouTigers> What's distal?

<Dr. Simpson(PHX> Distal is when you have more than 55 per cent of the intestine bypassed. Routine in DS

<MizzouTigers> I think I had 3ft removed.

<Dr. Simpson(PHX> it probably wasn't removed, but was bypassed, and that is proximal.

<**MODERATOR**> VICKIE YOU HAVE THE NEXT QUESTION

<Vickie> My surgeon said he is going to do the Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E) How much is he figuring on  bypassing, on average? My BMI is 53.4

<Dr. Simpson(PHX> Distal is 60 per cent, on average, or four yards so, that is how much you can expect. It should be just fine.

<**MODERATOR**> MINDY51@11WKS YOU HAVE THE NEXT QUESTION:)

<mindy51@11wks> do you lose more with distal or proximal

<Dr. Simpson(PHX> most at goal have made it there with a proximal bypass, and not a distal....

<mindy51@11wks> i see.. that is what I had....

<Dr. Simpson(PHX> distal is good for those who eat a lot of fat.

<**MODERATOR**> CHERYL YOU HAVE THE NEXT QUESTION:)

<Cheryl> What is the avg loss for a DS patient starting at 50BMI?

<Dr. Simpson(PHX> There is no AVERAGE--- although we always quote ten to fifteen pounds per month on average over the two years you can expect to lose all of your excess weight in the first year If you follow the program, and eat few carbohydrates, exercise four times a week-=- meaning you walk for 45 minutes and at a fast pace then you can get to a goal weight of BMI around 22 or even less. I threatened to get my BMI to 19 the other day and was told that such was not a good idea for me, but that is another story. Call me bony. Good luck.

<**MODERATOR**> AMY YOU HAVE THE NEXT QUESTION PLEASE:)

<amy> Which has less chance of leaks? Lap or open?

<Dr. Simpson(PHX> Overall, open has a decreased chance for a leak rate with the national average being 1.5 per cent for open and 3 per cent for laparoscopic, however there are some individual series of laparosocopic surgeries with a much less chance of a leak. Like Wittgrove in San Diego, for example, but, the national average is that lap has twice the chance as open.

<**MODERATOR**> KIMMIE YOU HAVE THE NEXT QUESTION:)

<Kimmie> What is the youngest you go with this surgery?  I'm almost 14

<Dr. Simpson(PHX> 18 is the youngest. Prior to that time you can develop better eating habits, and exercise routines, and the body is growing...

<Kimmie> I'm 5'5" and 330

<Dr. Simpson(PHX> so at that early age I would get into physical education, boot camp, and the like. It is tough, but you are still growing...

<Kimmie> I hope not

<Dr. Simpson(PHX> and before we move around guts and change absorption, it would be good to try some more conservative things so, lap band might be a route for you in the mean time. Good luck. Walk.

<**MODERATOR**> MANDY51@11WKS YOU HAVE THE NEXT QUESTION:)

<mindy51@11wks> i was just wondering ... about the carb issue... i drink the most of my protein and eat some carbs but i barely eat at all... is that going to slow me down... i am not losing as much pounds as inches

<Dr. Simpson(PHX> Your body doesn't care how you get the carbohydrates, or the source of the carbohydrates. Your body will process them per gram weight and they will become a part of you....

<mindy51@11wks> i am lucky if I eat 2 tims a day

<Dr. Simpson(PHX> inches are ok to lose, you will eventually lose the pounds. It doesn't matter how many times you eat...remember, the lion eats a water buffalo once a week....

<mindy51@11wks> even with the veggies.. that is how I get my carbs

<Dr. Simpson(PHX> your body doesn't care if you get 40 grams of carbs from a vegetable, fruit cake, or ...

<mindy51@11wks> so i shouldnt be eating any carbs?

<Dr. Simpson(PHX> from ice cream, it will break it down, and process it in the same way. So carbs are carbs, they just come in different forms. You should limit the carbohydrates for weight loss, you cannot, nor should you  eliminate them.

<mindy51@11wks> my ketones are WAY HIGH

<Dr. Simpson(PHX> but restrict them to 40 grams or so a day to lose, sixty to maintain. Well, that indicates you are keeping the carbs low, and that is ok, unless you are diabetic, in which case we have to determine if it is ketones or keto acidosis. good luck.

<**MODERATOR**> CHERYL YOU HAVE THE NEXT QUESTION:)

<Cheryl> How did you get started doing WLS?  Who did yours, guessing from your BMI goal that sounds like a post op?

<Dr. Simpson(PHX> I started doing WLS during my surgical residency which was in the paleolithic age just before Christ. I have not had the surgery, but struggle with twenty to forty pounds which comes and goes with my ice cream hobby and I enjoy doing it because it is fun to see people lose and get to goal and see their lives change....

<Cheryl> if it were 100+ pounds, would you?

<Dr. Simpson(PHX> and because my nice patients also give me ice cream to keep me from getting to a BMI of 19. Yes I would have it, without a doubt.

<**MODERATOR**> POCOO YOU HAVE THE NEXT QUESTION:)

<Pocoo (5 wks po)> I hear alot of people talk about hernia's is there a big chance of getting one after this surgery? And how do you prevent them from happening?

<Dr. Simpson(PHX> Fifteen per cent of people who have this surgery will develop a hernia, and most of them happen at about one month after surgery when you are feeling well and think you can lift something that you cannot so when the surgeon says nothing heavier than a certain amount, believe them/the fascia, or gristle, which heals slowly, is what keeps us together and we use suture to hold it until it heals, the suture dissolves, although some does not, but if you strain yourself. You will find that you make a hole in it, and you have a defect and stuff pops through and you have a hernia.

<Pocoo (5 wks po)> when can I pick up my son 6 wks?

<Dr. Simpson(PHX> which is another favorite operation of mine to do, but if you want to avoid it, I suggest you do it. Six weeks should be fine. Make him pick you up.

<Pocoo (5 wks po)> lol

<**MODERATOR**>AMY YOU HAVE THE NEXT QUESTION:)

<amy> I'm a big sweets eater, but the duodenal switch sounds like a better quality of life afterwards. What are your thoughts?

<Dr. Simpson(PHX> Well, sweet eaters can defeat any operation, because there is no operation where we can malabsorb the sweets. I like the quality of life after a duodenal switch, although with both surgeries you can have a normal quality of life. Remember my good friend who ate with me at a great restaurant and she is at goal. So it is possible with either surgery to have a good quality of life. Good luck.

<**MODERATOR**> ANNETTE YOU HAVE THE NEXT QUESTION:)

<Annette> Why do most people lose 60 to 70% of the weight rather than 100%?  Also,  do you think that a cardiac test is needed pre-op?

<Dr. Simpson(PHX> Well, those statistics are not universal, and if you lose 100 per cent of your weight you would be dead. Cardiac stress tests are needed in some individuals, but not all individuals, certainly for those with symptoms and those who have a history of heart disease, or who smoked in the past. Some do not lose weight with this operation, and gain weight back, those individuals are usually people who do not follow doctors orders, and it is difficult, but all will lose some weight but you can make it, because it is a great tool to lose a lot of weight. They don't walk enough. Or they eat too many bad things. good luck.

<**MODERATOR**> OKAY IFONLY545 YOU HAVE THE NEXT QUESTION:)

<ifonly545> what if you dont like veggies  what then after surgery

<Dr. Simpson(PHX> I don't like veggies, never have, never will. Some don't. You have to have a vitamin and mineral supplement..you need a source of fiber. You need to have a source of protein, and there are other food groups to get the stuff you need. You have to learn about food, and make food work for you, instead of you working for food..goat cheese ice cream is the exception, of course.

<**MODERATOR**> ANGIE H YOU HAVE THE NEXT QUESTION:)

<ANGIE H> I my first consult in a week...is there anything I can do to better prepare for it....such as things I might need for my insurance company to approve me quickly...I have United Health insurance

<Dr. Simpson(PHX> I suggest you put together the following time line: every diet you have been on, and how much you have lost and regained, if you can remember. Have the pharmacy give you dates of when you were on any diet pills; they keep those records that would be the most important. Your diet history. They will like that. Some places, like Jenny Craig, keep that infarction for you, but most do not. Good luck.