November 5, 2004

<Moderator> Welcome to tonight's chat with Dr Simpson. Chat starts at 4pm PST / 7pm EST. Please type in your questions and hit enter. Questions will be presented to Dr Simpson at the time of chat in the order they are received. Thank you! :)

<Dr. Simpson> Well, let me start out by saying it was wonderful to see so many faces at the Los Angeles Obesity Help conference this last week. We had a wonderful turn out and it was so nice to meet friends I have only chatted with online. The next ObesityHelp event is this weekend in Washington, DC -- which I will not be able to attend....However, keep checking for the event list of obesityhelp.com and I hope to meet some or all of you soon.

<Dr. Simpson> Now for the first of many questions as I listen to Alanis Morrisette as she sings "Everything."

<Philene> what is the mortality rate compared to other surgeries, like gallbladder?

<Dr. Simpson> The mortality rate of other surgeries is not the question...The question is the mortality rate of other surgeries in obese patients or morbidly obese patients, that is the question...And the answer, in early testing -- is that the rate is the same...however, some surgeries have less of morbidity and mortality...For example, the mortality rate with RNY gastric bypass is between 1 in 50 and 1 in 200, where the rate for laparoscopic adjustable band (lap-band) is between 1 in 2000 and 1 in 10,000.

<Dan> Hey Doc...2 years post op, weight fell off fast excep for 28 lbs. I eat just how I should, get protein, 125 oz water per day. Exercise 4 days a week but I can't lose this last 28 lbs.

<Dr. Simpson> Ah, you should have been at my talk in Los Angeles last week, that was what we were talkin about. The answer is simple, but it is also hard. First you need to figure out what your energy expenditure is, that is what is your basal metabolic rate...and with your activity level, you can multiply it by 1.3. From that point you can determine what you eat, and see where you can cut out the calories...Calories count, it doesn't matter if they are carbs, protein, alcohol, sugar, or fat... they all count, and they all matter, and your body keeps perfect count of them. The only answer is to manage it, and to manage it you have to measure it...so I suggest the following: Figure your BMR then keep track of what you eat and count the calories; do not skip meals, plan your snacks, and increase your walking. Your goal should be to get rid of those 28 pounds in two years, so that in one year you will be 14 pounds down, which means you have to increase your calorie output by 150 calories a day above what you are doing now. Good luck.

<Kimberley -CO -> what helps a surgeon decide whether a proximal or distal RNY is the best?

<Dr. Simpson> How do we decide proximal or distal. First we flip a coin...the major way that patients lose weight is not the malabsorption....The major weigh (way) patients lose weight is the restrictive part of the procedure. While there is evidence that super morbid obese patients can lose more with a distal bypass, there is plenty of overwhelming evidence that they can do this with no malabsorption at all...that is, lap band can do it all by itself.

<desie> Whats the best source of protein when it comes to protein shakes and stuff whey or soy protein? thanks

<Dr. Simpson> The best source of protein is food -- not a shake, not a bar -- but food. You have to eat three meals a day and usually two snacks, and if you eat protein first there is no reason that you cannot get enough protein in by the food you would take. However, if you have severe malabsorption of protein, you might need supplements, which taste something like sawdust wrapped in creasote...But the most bioavailable is whey protein.

<Desiree> What are some of the long term risks of surgery?

<Dr. Simpson> The biggest long term risk of surgery is what my son, Crow faced in Los Angeles....

<MODCROW -450# Lost> Umm?

<Dr. Simpson> So many women were hitting on him that they became jealous and his little black book had so many numbers that he got carpal tunnel from writing them all. If you do not take your vitamins or your supplements you can become very very ill....if you do not eat properly you can become severely protein and calorie malnourished....and the long term effects of that can be devastating. So, eat well, learn about nutrition, take your vitamins, and walk --- and be careful if the person who gave you their phone number tells you they are separated, but it is because their significant other went out of town for the weekend.

<Diana> How mobile must you be to have rny surgery?

<Dr. Simpson> You have to get to the hospital and get home.

<ROBERT JEFFERSON> CAN YOU DO LAP SURGERY ON ME ? I WEIGH 510 POUNDS IM 6 FEET TALL? ANY POSSIBLE WAY?

<Dr. Simpson> Well Robert, can I do it -- sure I can. But then again, I've been doing this for a long long time. Can some others do that -- maybe not. And, by the way -- you would be getting a lap band at that weight. Good luck

<LorLapBand> Can I drink alcohol at all with the band or will it get ruined?

<Dr. Simpson> Alcohol won't ruin the band unless you plan on injecting it into your port. However unlike food -- every bit of the calories in alcohol are absorbed -- everyone of them...and if you are wondering why weight loss has slowed down, then cut the booze and you will find that your morning headaches are gone, and that you can drive better at night.

<tessa> every time i eat any type of meat it gets stuck even tiny bites how can i flush it down and not puke it back up?

<Dr. Simpson> First we have to know what kind of surgery that you had....If you are not able to eat any meat, then you need to have something done to enlarge the stoma. If it is a lap band then some fluid needs to be removed from the port. If it is a RNY then you might need to be dilated, and the same with VBG. So, see your surgeon -- not being able to eat meat is not a good thing.

<bebe> im 5 yrs post op open rny and have had 4 hernia repairs and scheduled for a 5 th one in dec is there something i can do to prevent them from coming back

<Dr. Simpson> Hernias happen a lot, and they happen because many patients are not taking in enough protein and they are going back to activity too soon. So, I would suggest that you make certain you are getting in enough protein, and I would make certain that you do not lift anything over 10 lbs for six months, unless you like having hernias fixed.

<Wesley D> May i ask what are the best Vitamins to take after surgery?

<Dr. Simpson> You may, and there are a lot of vitamins that you can take, but we recommend a general purpose multivitamin....one that is absorbed easily, such as Bariatric Advantage Vitamins, and you need to have your blood tested periodically to make certain you do not have any vitamin deficiencies...and YOU MUST TAKE THEM -- vitamins do no good on the bathroom shelf -- honest.

<tricia> i am having ryn y open in 5 days what is this drain for ive heard about the surgeon never mentioned it to me???

<Dr. Simpson> Some surgeons use drains, some do not, and sometimes during the course of surgery if we feel we need to put a drain in we will. It is not a big deal at all, and if you need one, then you need one...and they come out like linguine --- in fact, in my book I have a cartoon of this, and I tell people that if you get some body fluids on your clothes after a drain is removed that it is called linguine with drain sauce. But I am sick.

<Lorri Fuller> I was wondering after you have surgery im having open rny how many weeks do I havbe to go without having sexual relations?

<Dr. Simpson> I typically tell my patients to abstain from sex for 17 years and somehow they never follow my advice. You can resume when you feel comfortable, and you have a willing partner. But don't lift anyone, or get too rough-- you do not want a hernia...And use a mechanical form of birth control. We do not want post op babies.

<ssbbwnj> At what weight does the risks of weight loss surgery get even greater? What do you feel is the best weight loss surgery for a person with a high BMI over 75?

<Dr. Simpson> Over a BMI of 55 the risks increase, and the best weight loss surgery for such a high BMI is whatever your surgeon does. Probably with a BMI that high I would put the person on Optifast for six weeks and see the weight decrease.

<bebe> with my last surgery i had a bad wound infection i was wonering if it is likely i will have another wound infection someone told me once u have a wound infection u always have wound infection after surgery

<Dr. Simpson> That is not always the case. In fact, often it is not the case. So, take your vitamins, use Hibicleans before your surgery for three days in a row and pray.

<Barbara> LOVE YOU BOOK DR SIMPSON BEST BOOK OUT THERE INFORMATION WISE ON THE MARKET. ANY NEW ONES COMING OUT SOON?

<Dr. Simpson> We have a new workbook coming out for patients who are trying to get to goal and to stay there and we have a book for primary care providers, and a book about surgical success from patients who got there.

<bebe> is there any chance after a TT to have a recurrent hernia

<Dr. Simpson> Recurrent hernias are always a risk after a hernia operation.

<todd> i wanted to know how much protein i need 6 months post op i started at 450 pounds i lost 100 so far. thank you dr simpson

<Dr. Simpson> 80 to 100 grams of protein per day . It is a complicated formula, and we have a nice table in the appendix of our book.

<Becca (pre-op)> Is it safer to have open rny or lap?

<Dr. Simpson> Both are safe, and both do well. And if your surgeon does open, then that is the safest. If your surgeon does lap then that is the safest.

<BETH> I HAD SURGERY 4 MONTHS AGO AND I STILL HAVENT HAD MY PERIOD WILL THAT GET NORMAL ONCE I START LOSING ALL MY WEIGHT?

<Dr. Simpson> Well, sometimes people have commas instead of periods because it is one long period. It is common for patients to have irregular cycles-- please make certain you are not pregnant. And please see a gynecologist just to make certain. I don't do gynecology, just a personal interest.

<dee> What can i do to be a candiate for this surgery. i need help and dont no were to start

<Dr. Simpson> First, research the procedures and the insurance that you have...and Theresa, Crow-- what is the best source????

<TheresaC~~> obesityhelp.com, then www.drsimpson.com. And your book of course, which i must add is sold in the Obesityhelp.com store ;)

<Dr. Simpson> Well, not a bad start...and that will help you find out a lot about the surgery. Oh, that book, well it is the most comprehensive book about weight loss surgery on the market today....Filled with diagrams, techniques, humor, and lots of good information. Find out about your insurance, and with those sources you will be able to go forward. Finally, to get this surgery you need to be obese. If you are not obese, then you will need to gain some weight, and I think I can help you there.
Good luck.

<Sharon R> How fast does the weight shed off after the Lap procedure?

<Dr. Simpson> Weight comes off depending on what you eat, not on what surgery you had...you must have protein in your diet, and you must have essential vitamins and minerals....and weight will come off fairly fast, usually ten to fifteen pounds a month, and it can come off faster or slower, depending on how much you have to lose.

<LittleRed> Medicare just agreed to keep covering WLS for those with co-morbidities. Do you think that in the future they might agree to cover it for those that have a high BMI but no co-morbs?

<Dr. Simpson> They have covered those with a high BMI with no co morbidities in the past. It depends on what part of the country that you live in. But I think that Medicare is trying to figure out what they are supposed to do...but I have no doubt they will come to the right conclusion.

<Connie Sue> At your talk Doctor, you spoke about how we absorb all alcohol calories...I'm curious...Is that true of ALL liquid calories?

<Dr. Simpson> No, alcohol is a source of calories in and of itself. Liquids have calories from things like corn sugar or syrup and things like that, which have four calories per gram, as opposed to 7 calories per gram which is alcohol.

<Dan> Doc I had my rmr tested today....it was 2050. I on average am getting between 850-1200 calories per day

<Dr. Simpson> There are 3500 calories per pound, so that can be figured out easily. You will lose well.

<Rochelle> Hi Dr. Simpson I am almost 4 yrs post op at the time of surgery I was 545, my doctor never had a patient of my size when he did my surgery, 2 years later I was 225 down and then I stop losing weight for the past almost 2 years I have gained about 40 pounds. I am going to weight doctors for pills and shots, walking and trying to eat right everything I have done in the past to lose weight. I started do research about revision surgery and now I feel that the doctor did not bypass enough

<Dr. Simpson> It is not the bypass that you need....it is not a revision...It is instead figuring out what you are putting in and what you are taking out. That is how many calories you are burning and we can determine from there...It is working and measuring the things, and I suggest you get a band from healthwear.com

<Sharon R> when you say distal bypass what exactly does that mean?

<Dr. Simpson> That means that the amount of small bowel is bypassed. In a distal bypass you need to bypass more than 100 cm of small bowel, according to some, or for many of us it is greater than 55 per cent of the small bowel.

<Rochelle> He only bypassed 100cm do you think for my weight I should have had more bypassed and what type of revision should I be seeking

<Dr. Simpson> You do not need more bypassed. It is the amount of food you put in, and it is the amount of exercise that you put out....and that is what we need to calculate. The only reason for a revision is if there is a technical problem, such as a stoma enlargement...too large a pouch. But the size of bypassed segment is NOT a reason for a revision, without having something else...Ok, so the reason for revision is if there is a technical problem with the surgery...not because of not losing weight enough.

<Trixie> Can RNYs be revised to LapBands?

<Dr. Simpson> Yes

<Kim- Colorado> so if you have a BMI of 53.4 would you say distal is better than a proximal bypass?

<Dr. Simpson> The best thing is to have a bypass. You do not need distal. The major reason for weight loss is the restriction -- making a smaller stomach....It IS NOT the malabsorption. More is not always better.

<Philene> Do you feel lap band would be less effective with a 240# patient? dr recommended lap gastric bypass

<Dr. Simpson> Although I do DS so, I do a lot. No, a lap band is not less effective, at all. In fact, long range studies have shown that lap band at three years is more effective than rny.

<Allie> What is considered super obesity and what, in your opinion is the best, most effective surgery for them?

<Dr. Simpson> Super morbid obesity is generally over a BMI of 55 and the most effective surgery for them is that surgery that their surgeon does.

<Philene> are there any things a pre-op can do to ensure the best possible outcome?

<Dr. Simpson> Take vitamins, have good nutrition, and walk. Start a walking program...a long walking program...and go for it.

<donna> I have heard many say they had to lose 20-30 pounds pre op why is this?

<Dr. Simpson> It shows that you can lose weight, which may or may not show ultimate compliance. And that is the reason

<tricia> am i to big at 380lbs for open ryn

<Dr. Simpson> No, you are not too big at all...You are just right...Mmmmmm (Goldilocks)

<heather_4daypo> I am 4 days post op i still feel like I am walking like a 97 year old women is that abnormal?

<Dr. Simpson> Well, if you are 97 years old, then it is. Many patients feel awful for the first twelve weeks, unless you are having a lap band which has less of that, but let us face it...First of all, whenever you have surgery, no matter what type, you are going to feel like a small worm in a big world full of birds and you won't be able to concentrate as well, and you will be tired a lot. And the best thing to do is get off the couch and walk, and walk some more...and walk and walk and walk.

<April> Do you have any experience with Health Assurance Insurance? If so, what can you tell me about their requirements?

<Dr. Simpson> In every state the insurance companies have different requirements, so I am sorry, I have no idea.

<Daehlia> Hello Dr Simpson I have just had my surgery 3 weeks ago and was told for the first 4 weeks I was told to stay on liquids but the liquids weren't filling me up like they did the first week so by the third week I begain eating solids. I am still loosing weight eating solids but want to know if I am damaging my band?

<Dr. Simpson> Well, you will be hungry on liquids, that is something that happens, and that is ok...It is ok to feel hungry, honest it is, and everytime you feel hungry remember that you are losing weight.

<marcy> Is there a lot of risk with blood clots after surgery and do most people get them after surgery

<Dr. Simpson> Most people do not get them, and most of them do not have them, and it is thankfully rare.

<TwinMomma> Hi Dr. Simpson--surgery is 1 month from tomorrow, nerves are starting to kick in---any gems of wisdom?

<Dr. Simpson> In one month you will be ON YOUR WAY...well on your way...and you will be happy, but until then, remember that it is a process, so begin that process in this way: Get vitamins, start a walking program, and get my book -- (it has a list).

<j nite> what does it take to get bc bs of ms to pay for this procedure, have already sent 2 letters from diffrent doctors?

<Dr. Simpson> Hard to know, again, in various states there are various ways that these insurance companies work...so, work with your surgeon. They are probably the most knowing in that state.

<Diana> I was told by my surgeon that I would have to walk after surgery or he could not do it. Is this true? I can do some walking but not very far - About 10 feet.

<Dr. Simpson> Walking is key. Walk, and walk, and walk. Some cannot because of disability, and that is ok---That is not the issue. The real issue is those who WILL not.

<Becca (pre-op)> Do I have a greater chance of infection since I had hip replacement 6 months ago?

<Dr. Simpson> No, not at all

<Philene> When people die from gastric bypass, what are the main reasons? (i.e. heart attack, infection...)

<Dr. Simpson> The main reason is pulmonary embolism.

<Judie> I have a few questions...I had my surgery in July 2002. I STILL cannot eat chicken, pork or beef (unless the beef is ground up in spaghetti sauce or chilli). Shouldn't I be able to eat these by now or is this the way it will be from now on???? My sugars keep going too low (20 mg/dL to 61mg/dL). I don't want to keep having hypoglycemic reactions and don't want to take glucose to remedy the problem..Do many post WLS patients have this problem?

<Dr. Simpson> No, most do not, and you need to be ablet o eat those meats, so that needs to be worked up. So see your surgeon, and go from there.

<heather_4daypo> This Jp drain I have keeps getting clogged will that cause an infection?

<Dr. Simpson> Anytime you have a drain in then you have a chance of infection. So getting it clogged happens.

<Judie> Are there any "tips" you can offer to help in getting insurance to cover excess skin removal???

<Dr. Simpson> Save your pennies.

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

<Kendra> I recently had a hysterectomy and suffered a pulmonary embolism afterwards. Am I at a greater risk for an embolism with WLS?

<Dr. Simpson> Yes, you are.

<Moderator> Thank you very much Dr. Simpson. We enjoy your chats every week. We all thank you and have a great weekend. Thank you members, for more information about Dr Simpson, please call 602-234-8995, fax 602-230-8344, or visit www.drsimpson.com. Please join us Friday for another wonderful Q&A with Dr Simpson. Great way to spend an hour on Friday afternoon!

<Dr. Simpson> Thank you all