Bad Behavior Equals Consequences

Remember the vocabulary lesson from last week? Let me explain what that was all about.

Those who have read my blog for a long time know that I don't mince words and I don't gloss over the hard parts. I tell it like it is. My behavior - both good and bad - are laid out open for all to see. It's a decision I made a long time ago and one I am glad I've stuck with all these years. So today I'm going to tell you about my bad behavior and the price I'm paying because of it.

For the past several months I have not been faithfully taking my vitamins like I should be.

I'd estimate that I would get about 40-50% of my daily doses most days. I've gotten lax and letting a bit of rebellion and laziness take over even though I know better. There are times when I'm 100% faithful to my vitamins but then there are times when I just "don't wanna play" and don't. (Those who are further out might understand that mentality about being tired of "playing house in the WLS world" - newbies have a hard time comprehending it.) So I'm here to confess my bad behavior and openly commit to doing better. I'm not here to make excuses. There are plenty of reasons but I won't bother wasting your (or my) time listing them. I signed up for this, I need to play by the rules whether I feel like it or not.

So what's my punishment?

I got my lab results back from my 3-year follow up appointments and there are several readings that I'm very disappointed in and worried about. So far nothing is out of range or officially deficient... but I'm so close they might as well be. Here are some major concerns:

Vitamin D -- 34
Ideally we want our lab results to be 80-100 to see optimal health benefits (reduced risk of certain cancers, etc.) Anything that's 30 or lower is a deficiency. A year ago my reading was 58, I increased my dose to raise that number and had a re-test and was able to get my results up to 82 and wanted to maintain that excellent reading. So in 6 months I've dropped nearly 50 points on my lab results because I haven't faithfully taken my vitamin doses.

PTH (parathyroid) - 49

This is one I'm worried about. A high reading is very bad because it means my body is pulling calcium from my bones to provide the calcium my body needs to maintain blood calcium levels. Last year, at the time of my diagnosis with osteopenia, my PTH was 24 - an excellent number. Now it's 49 and my Vitamin D has tanked at the same time.... so bad news for my bones! DEXA scan is scheduled.

Vitamin B12 -- 680
Ideally we want our lab results to be 1000-1500 and anything below 500 and we could start to see signs of deficiency such as fatigue or nerve damage (below 400 and things get very serious). Even though the lab result range says 211-900, these ranges are currently in question and being re-reviewed. A year ago my lab results were 1087.

Vitamin B1 - 11
My levels have dropped from 21 (top of the range) to 11 (low end of the range). Gee, ya think maybe I should be taking my B-complex a bit more often, huh?

Ferritin - 11
My levels have steadily dropped from the first round of labs but none of my doctors seem to be worried about it. I'm worried though. The level of deficiency is a result of 10 and I'm only 1 point above deficient. Being more faithful with iron doses is key.

Everything else came back alright. I've requested a re-draw of lab tests in 6 months. I've confessed all to my doctor and I've beaten myself up about it until my butt is black and blue. I could have just kept this information to myself and fixed my behavior. I'm sure I'll have some readers who will think poorly of me for preaching one thing and doing something else. I'm sorry for that.

I'm telling you this because I want to reiterate the fact that this journey is hard. It's freaking hard! Some days it's harder than others. If you had asked me months ago if I'd be writing a post like this I would have laughed in your face -- I know why vitamins are so essential, why would I ever jeopardize my own health? But bad behavior seems to find a way to justify itself, doesn't it?

Accountability is essential too, so this is my way of being accountable to myself, to you and to anyone who might come after. Today I'm on track with my vitamins even through I'm running about 2 hours behind schedule I'll be able to finish on track. Yesterday was a bit tougher and ended up missing one dose of calcium. Tomorrow is a new day and I'll do my best.

Thanks for listening.
~Pam

Vocabulary Lesson

Noncompliance: The failure or refusal adapt one's actions to a rule or to necessity.

Misbehavior: To behave badly or in an inappropriate way.

Naughty: Behaving disobediently or mischievously

Imperfect: characterized by defects or weaknesses

Perfectionism: a disposition to feel that anything less than perfect is unacceptable

Consequence: Something that logically follows from an action.

Punishment: a penalty inflicted on an offender

Penance: An act of self-mortification performed voluntarily to show sorrow for a wrongdoing

Rehabilitation: to restore to a condition of usefulness and constructive activity

Compliance: to act in accordance with rules

Seeing a pattern here? Yeah... someone hasn't been following the rules like she should be and suddenly she's paying the price. She's highly pissed at herself. She'll be reporting in later this week with the details (after finals week) and what she plans to do about the naughty behavior.

~Pam

 

Which Vitamins When?

http://www.nataliedee.com

This list has been around for a while but apparently it's never been posted here on my blog. I pulled it from my OH profile (it's also in my protein book) -- and I'm getting it over here for quick reference too.

These are the basic interaction rules when figuring out when to take your vitamins:

Calcium and Vitamin D are Friends --- take them together, they help each other absorb better. Your body can only deal with 500mg at a time, so split up your doses into 3 or 4 doses per day to reach your 1500-2000mg daily goal. Calcium tends to absorb better when taken with a meal, so schedule it that way if you can.

Iron and Vitamin C are Friends --- Iron needs an acid environment to break down and Vitamin C does that job so make sure they are in your tummy at the same time. Iron does not like food, so take it on an empty stomach. However, if you get an upset tummy because of the iron, pick a non-dairy snack.

Iron and Calcium are Enemies --- iron and calcium fight for the same cell receptors in the body and calcium is bigger and badder and always wins. Which means the iron is simply excreted from the body and not used at all. Keep iron and calcium at least 2 hours apart from each other.

Vitamin B's are a Family --- they work together as a team and are best taken at the same time. Your Multi-Vitamin has many B's in it, so take it together with your biotin, B12 and B-complex if you're taking those too.

~Pam

Simple vs. Complex Carbohydrates

Here is a general overview of carbohydrates and which foods to choose as part of your healthy diet. There are two main categories of carbohydrates:

Simple and Complex.
Some people call them bad carbs and good carbs... I personally prefer to not call any food bad. There are no bad foods (or evil foods) - food is just food. We need to focus less on the moral standing of food and focus more on making the right choices that are healthiest for our bodies. So we'll stick with simple carbs and complex carbs for now.

A quick definition:

Simple Carbs -- digested quickly. Many simple carbohydrates contain refined sugars and few essential vitamins and minerals. Some examples include: sweet treats (cake, cookies), high-sugar fruits (pineapple, bananas), "White Stuff" (white bread, pasta, rice, potatoes, sugar) and most things that come in a box or are highly processed.

Complex Carbs -- digestion takes longer. Most complex carbohydrates are packed with fiber, vitamins and minerals. Examples are vegetables, low-sugar fruits (berries), whole grain starches, legumes, dairy - the more natural and whole the food, the more likely it is to be complex.

So after WLS we want to avoid the simple carb category except in instances of extreme moderation. Just because you have WLS doesn't mean you're never allowed to have another Christmas cookie - but you can't make simple carbs a part of your everyday eating plan. Instead we should focus on complex carbs that are more wholesome and packed with fiber and nutrients.

Our body NEEDS carbs for proper function. Our brain alone needs about 40g carbs a day for clear thinking and rapid nerve response - and other vital organs in our body prefer to get their energy from glucose (which is the energy that carbs turn into when they are digested). Studies have shown that anything less than 100g carbs per day is considered low-carb and can put your body into ketosis (which is not desireable).

So once you're several months out from surgery and able to eat a larger variety of foods, you should be getting no less than 100g carbs per day just to keep your body happy and functioning properly. Depending on your exercise level and overall calorie intake, this number may be higher.

I shoot for about 35-40% of my calories to come from carbs and at 1400 calories a day, that translates to 140g per day. (there are 4 calories in each gram of carbohydrates) -- additionally I shoot for 40% from protein and 20-25% from fat and try to get 25-30g fiber per day.

Also remember that within the nutrition label there are several things listed under the carb category. Fiber, Sugar and Sugar Alcohol. Fiber is essential and the higher the number the better. Sugar we want to limit of course and I shoot for less than 10g per meal/snack. Sugar Alcohol, in theory, is not absorbed by the body so you don't need to worry about those... but many people have problems with sugar alcohol and it can cause gas, bloating and diarreha, so be careful with this one.

The only way to really know what the true carbohydrates in a food include is to look at the ingredient list. Over time as you learn more and more about what different foods/ingredients are and their nutrient make up, you'll be able to recognize which things are carbs, proteins or fats. And when you spot a carb in the ingredient list, you'll eventually be able to automatically categorize it in your mind as simple or complex. It takes practice and there's a learning curve to it - but it's a valuable skill to have and worth the effort to learn.

Right after my surgery when I was so obesssed with food, I'd go on field trips to the grocery store. Leaving my purse/wallet in the car I'd just go in and walk the aisles and read labels of different types of foods to understand them better. I'd do a bit of research at home on a certain nutrient, then I'd go around the store looking at labels to see how that nutrient was used in various foods. One day I did a sodium field trip, one day a carb trip, one day a whole grain trip... that's the way to learn this stuff. Just soak in as much as you can.

Nutrition is a learning process. Learn a little bit each day and before long you'll be comfortable with picking the right foods for your overall good health.

What Vitamins Do I Take?

I'm ofen get asked what vitamins I take and where I buy stuff. I got the question again tonight and actually took the time to type it all up. So I'm sticking it here to refer back to later.

I recently wrote blog posts on Organizing My Vitamins and Calcium Options ... they show pics of my vitamins and stuff if you want to take a peek.

The list below is MY vitamins based on my own lab results and more extensive than the basic vitamins needed right after surgery ... nobody should follow this list but me, it's just an example of one person's pill line-up at 2+ years out. For information on what the basic vitamin plan is for your surgery type, see the ASMBS Nutrition Guidelines (chart on pages 7-8).

What you see below is an ever-evolving schedule - listed below happens to be what my current routine looks like. It was actually different yesterday than it is today because I just replenished my supply of fish oil that I've been out of for a couple months. And just a week or so ago, Andrea made me change my copper and zinc doses to be alone because I was screwing it up and taking them with the rest of my vitamins, but they need to be alone and treated just like iron. So those 2 doses in the middle of the evening are new to me and tough to remember. I'm also just starting iron since my GYN took me off Depo Provera so I'm no longer a non-menstrating woman. So, as of February 27th... this is what I take.

(And yes, I realize that some of these doses are less than 2 hours apart on the schedule. That's not usually the case in real life because the times are never exact. But even if it's only 1.5 hours between instead of 2 hours... I guess that's better than not taking it at all because there just aren't enough hours in the day.)

My Vitamin Schedule

7am -- in my protein shake

• calcium +D (UpCalD from Amazon)

9am -- or whenever I arrive at work and get settled at my desk

• iron and chewable Vitamin C (iron is Feosol from Walmart. Vitamin C is chewable GNC)

11am-ish -- taken about 30-40 minutes after I eat breakfast and start drinking again

• Centrum adult chewable multi (from Walmart or drug store with manufacturer coupons)
• B-100 Capsule (Puritan Pride or GNS) I need capsules, can't deal with smell of tablets
• Vitamin A - retinal (from Vitalady but it's a very strange pill that dissolves too fast, will switch to new brand when this is gone)
• 500mg Magnesium (Puritan Pride)
• Vitamin D3 - 2000IU (Spring Valley from Walmart - it's often out of stock in stores)
• glucosamine and chondroitin (to help with knee-joint pain) (Puritan Pride)
• Fish Oil Capsule (Spring Valley or whatever brand is on sale)
• Stool softener (Equate - Walmart store brand of Colace)

12:30pm, 2:30pm, 4:30pm

• calcium +D (Bariatric Advantage Wild Cherry Lozenge and/or Citrical Regulars)

6pm-ish -- on empty stomach

• copper (Puritan Pride)

9pm-ish -- on empty stomach (or an hour after dinner)

• zinc (Puritan Pride)

11pm -- bedtime dose

• Centrum adult chewable multi
• Probitotic (Spring Valley from Walmart - blogged about it here)
• 500mg Magnesium (Puritan Pride)
• glucosamine and chondroitin (Puritan Pride)
• Fish Oil Capsule (Spring Valley from Walmart)
• Stool softener (Equate - Walmart store brand of Colace)

3x per week

• B12 sublingual (Walmart or Puritan Pride)

1x per week

• 50k Vitamin D3 (BioTech on Amazon)

 

Notice I have a ton of stuff from Puritan Pride. They have awesome sales. I caught them on a "Buy 2 get 3 free" sale last time I orders... got enough stuff to last me a whole year of some of my supplements. I also buy Centrum when I find it on sale and have some manufacturer coupons. Last round it was on sale for $6.99/bottle and I had $3-off coupons... so I got a supply that'll last me about 11 months for the price of 2 months at regular price.

 

~Pam

Calcium (again)

I know, I know, I know... I talk about calcium a lot.  Do a search here on my blog and you'll get to read all about it.  But today I'm going to share some pretty pictures and some helpful links.  I promise not to get into the science of calicum on this one. 

I often get asked what kind of calcium citrate I take.  My answer is: "I use three different brands because I need the variety."  I tend to get bored easily with stuff and since I have to take 4 to 5 doses of calcium per day, I need to have options. 

Here's a pretty picture of my calcium choices:



Bariatric Advantage Calcium Lozenges - Wild Cherry - the name is deceiving because they aren't really lozenges.  When I hear the word lozenge I think of a hard candy cough drop type of, but these are more the consistency of a sweet tart.  You can either suck on them or chew them - or a combination of both.  The Wild Cherry flavor is my favorite - it's tart and sweet and is great to use as "dessert" after a meal.  I also enjoy the Cinnamon flavor but those suckers are definitely hot if you chew them right away. They also make Chocolate and Mint flavors. These are a bit pricey, but this is my splurge since I enjoy the taste so much.  The best price is to buy them directly from Bariatric Advantage and sign up for their auto-ship program; this will save you shipping costs. Or you can also buy these on Amazon.

UpCalD - this is a flavorless calcium citrate powder that mixed into anything.  I usually add it to my protein shakes in the morning, but it also works fine in plain water without altering the taste.  For those who don't want to swallow a bunch of pills all day, this is a great option.  They also make UpCalD Chewable Tablets and UpCalD To Go Packets.  Super convenient and super economical.

Citrical Regulars -- these pills are available everywhere in local stores.  You can get the brand name or the store brand (I buy the Equate brand from Walmart).  Just make sure you're grabbing the right generic bottle because they often have Citrical and Caltrate right next to each other.  Citrical is calcium citrate but Caltrate is calcium carbonate - which is the wrong kind for us.  These pills are a bit large for some people so you might also consider the Citrical Petites... slightly smaller pills with a smaller dose (200mg per pill vs. 315mg per pill).

AND.... I like my stuff to be pretty, of course.  So I actually keep my Bariatric Advantge Calcium Lozenges in a crystal candy dish on my countertop.  I don't pack my calcium for the day into my daily pill organizers (calcium is too big for those little compartments) -- so when I'm packing my daily pills I'll grab whatever calcium I need for the day from the candy dish or from the Citrical bottle. 



So, besides the three choices above, there are plenty of other calcium citrate options on the market.  Here's a list to get you started in  your research. 

TwinLabs --- Chewable or Capsules

Vitamin Shoppe -- Capsules or Tablets

Celebrate Vitamins -- Chewable Calcium Citrate (comes in Wild Cherry or Berries N Cream flavors)

Bariatric Advantage Chewy Bites (little nuggets of candy-like desserts) -- Chocolate or Lemon or Berry

Calcet Creamy Bites -- same as above but different brand.  Lemon

Bariatric Advantage Crystals (a powder similar to UpCalD) - Unflavored  or Lemon/Lime or Berry

Building Blocks Calcium - Chewable or Capsules

Many ask about liquid calcium citrate.  You have to be really careful with these options and read the label well.  Remember, you're looking for the words FROM or AS -- Calcium FROM Citrate or Calcium AS Citrate.  See chart below.  Here are a few of the most popular brands of liquid calcium on the market:

Swanson Liquid Calcium Citrate -- A good choice.  You get 500mg calcium from citrate per 1 tablespoon dose plus Vitamin D and Magnesium.  But be aware that there's 40 calories in each dose. 

NSI Liquid Calcium Citrate -- A good choice.  In each 1oz dose you get a full 500mg calcium plus Vitamin D3 and Magnesium.  There are only 20 calories per dose in this brand.

NOW Liquid Calcium - A good choice.  In each 1oz dose you get 500mg calcium plus Vitamin D3 and Magnesium.  40 calories per dose.  And this brand seems to be cheaper than the above two, so that's a bonus.

Below are the brands of liquid calcium you want to AVOID!
BlueBonnet Liquid Calcium  - This is NOT a good choice.  Notice the label says "Calcium Citrate" which means you need to multiply by 21% to calculate the actual elemental amount of calcium you'll get.  Two tablespoons (1oz) is 1200mg calcium, but after the calculation, you see that a dose is actually only giving you 252mg calcium citrate.  So you'd need 6 doses (12 tablespoons) per day to reach your minimum 1500mg calcium citrate requirement.

Tropical Oasis Liquid Calcium - This is NOT a good choice. The same as BlueBonnet, you get 252mg per half-ounce dose. To get your max limit, you'd need 1oz per serving and 3 to 4 servings per day. Which means you need 4oz total per day ... making for a very expensive calcium supplement (about $3.75 per day compared to about 66-cents per day for Citrical).  But at least they have labeled their bottle to reflect the 21% calculations so their customers know exactly what they are getting.

Lifetime Liquid Calcium -- I would avoid this one too. I really don't know if this is good or not.  The label is vague and you don't know if you're getting 750mg calcium citrate or 750mg calcium that's been calculate for elemental.  And even if it's 750mg per dose, it's common knowledge in the medical community that a body can only absorb 500-600mg elemental calcium at a time - so that makes me suspect it's not calculated for the 21% formula. The label simply says "calcium elemental" which is not an industry standard way of labeling and causes more confusion than understanding.

Wellesse Liquid Calcium -- This is NOT a good choice. It is a combination of calcium citrate and calcium triphosphate. Calcium triphosphate is not well absorbed by anyone - it's worse than calcium carbonate.  OH's resident vitamin guru, Andrea, actually called the company to inquire how much of the formula was citrate and how much was triphosphate - 80% is citrate. But when you run the numbers to calculate for elemental calcium, you end up with 200mg per dose. For the details of her discussion, see this OH thread.

Understanding Calcium Citrate Labeling
500 mg Calcium AS Citrate = contains 500mg elemental calcium
500 mg Calcium FROM Citrate = contains 500mg elemental calcium
500 mg Calcium Citrate = contains 21% elemental calcium = 105mg
500 mg Calcium = it’s probably calcium carbonate, but who knows for sure! If it isn’t properly labeled, don’t buy it.


READ THE LABEL & DO THE MATH
Make sure you read the label to determine serving size of a full dose. Then do the math to determine how many tablets you need per day to reach your total calcium goal. Normally calcium citrate requires two pills to equal 500mg, so check the serving size. Remember, your body can't deal with more than 500-600mg calcium at one time, so scheduled your doses 2 hours apart.

My Vitamin Organization

Today I'd like to share some photos of my vitamins.  I know... exciting, right?  But really, I do get asked about this a lot and I feel as if I have a pretty good routine so figured I'd share it here.

Disclaimer:  I'm 2+ years out from surgery so the exact vitamin regime I use is not going to be the same that you use.    You should start with the base vitamin routine the ASMBS recommends, then add or subtract based on your own lab results.  No two people will be exactly the same.  Always check with your doctor before you add new supplements.

STORAGE -- I keep all my currently-open bottles of vitamins in a plastic bin. This represents the supplements that I'll be using to sort my doses into the pill organizers.  By keeping them all together it's easy to just open the drawer and pull out one thing.  I also tend to stock up on vitamins when they are on sale, I keep those in a separate bin in the same drawer.



REMEMBERING -- To make sure I don't miss anything I always print a fresh copy of my vitamin and medication schedule from the website www.MyMedSchedule.com -- it's a free website and it's a great help in keeping track of all the stuff you have to remember.  I keep this list next to me while I"m sorting to make sure I"m doing everything right.





THE BIG SORT -- I use a 7-day AM & PM pill organizer and it's got the push-button closure so it won't accidentally open if it's dropped. The brand I use is Ezy Dose - I got it them at Walmart, I think.  I have three sets.  And yes, I sort 3 weeks of vitamins at a time.  This is probably because I'm lazy...efficient ... and I got tired of going through this routine every week.  Since I've gone to the three week system I feel like it's almost automatic and not such a big deal all the time.




And here's a photo of all three weeks completely sorted and lined up for me.  It makes me happy to see it all done.




DAILY -- So the next big thing is my daily routine.  I don't carry these big organizers around with me - way too cumbersome.  Instead I have a mini, daily organizer that goes into my purse each morning (in fact, I usually get it loaded and into my purse the night before when I'm taking my bedtime vitamins).  This is also one of those Ezy Dose push button organizers.



Need help figuring out a system that'll work for you?  Here's a great website with hundreds of different pill organizers.  Forgetting the Pill

If you've got a routine that you'd like to share.  I'd love to hear about it.  Leave a comment or post your routine in your own blog and link to it here.  The more ideas we have, the better system we can develop together.

~Pam

Going Clean

Going clean (not coming clean) -- means that my diet will be lean, dense protein; good healthy carbs and good fats.  Drinking all my water and taking all my supplements.  Clearing away the junk and following the rules I know to follow.

I've spent the past few weeks feeding my body crap and I'm feeling the effects.  I'm dragging, tired and sluggish and I don't feel the same vitality that I do when I'm eating a clean selection of foods.  And because I've slacked so much on water I'm feeling run down and have had a low grade headache for a week or two now.  Unfortunately with the altered holiday schedule I've also missed a lot of doses of vitamins and calcium.  So yeah, I've screwed up a lot.

Because of the crappy food I've been eating my Reactive Hypoglycemia has been hitting me hard too.  Friday morning after having a protein shake for breakfast, my blood sugar crashed an hour later (count of 43).  There was no reason for it and the high protein shake should have kept my levels up -- but I suspect the bad eating on Thursday night resulted in the morning crash.  Then later on Friday afternoon after a meal high in protein, I crashed again. It scares me.  I don't want to spend my life wondering if my blood sugar levels are going to be fine or drop very low unexpectedly. The fear alone is enough to get me back on track.

So yeah, I had my holiday fun.  Ate lots of Christmas cookies and way too many carbs and a bunch of fatty protein choices.  But now I'm turning the corner on the New Year and I'm back on the program again.  This is not a resolution (because I hate that word) -- but this is what I'm facing as I begin my new day tomorrow:

1. Use my FitDay food journal at least 4 days per week to keep  me accountable and aware.
2. Figure out where I need to be with calorie intake, plan the day's menu and stick to the plan.
3. Eat at least 100g good quality, lean protein per day in either protein supplement or meat.
4. Limit carb intake to fruits, veggies, dairy, legumes and whole grains only. 
5. Drink 64oz water per day.
6. Take all doses of vitamins and calcium per day.
7. Be active.

I'm not perfect and I've never claimed to be.  These past few weeks have proven to me that I need to stay on top of my game because it is way too easy to fall back into bad habits with food. I may have the best weight loss tool known to man living right inside my abdomen, but unless I use that tool it isn't going to work for me.  Just like a hammer can't drive nails on it's own - it needs a carpenter to use it as the tool it is to get the job done. 

~Pam

Probiotics

This past summer there was a study published in the Journal of Gastrointestinal Surgery about the use of probiotics after gastric bypass surgery.

Probiotics are the so-called “good” bacteria found in yogurt as well as in over-the-counter dietary supplements that help in the digestion of food. It was shown that "the probiotic group attained a significantly greater percent of excess weight loss than that of control group." How much more? Nearly 10% more weight was lost at the 3-month post-op mark. The study also showed that B12 levels were higher in patients who took probiotics than in those who did not. Read the whole story here.

So why am I posting this information now -- 5 months after the breaking news? I started taking the Acidophilus tablets shortly after I learned about the research. Remember, back in July I was desperate for anything that'd help me lose more weight and if it worked for new post-ops, maybe it would for me too? The other benefit that I kept hearing about was related to digestion and constipation - people were reporting happy bathroom visits within a week of taking the probiotics. So why not give it a shot?

What happened?

We all know the weight loss never came. But that's a whole other issue. But did it help with constipation? Yes it did! It essentially cured 20 years of chronic constipation for me. For most people they saw a difference in a week or two, but for me it took about five weeks. I still keep up my normal routine of fiber, water and fat to keep the digestive tract running - but the probiotics was the last thing that made a big difference.

What do I use?

After reading the original published study I discovered that the researchers used a regular old probiotic from Puritan Pride -- a tablet that had 3 billion live cultures. They didn't use the type that health food stores sell that claim they must be refrigerated at all times. Those are fine, but are we paying too much if we choose that type? Maybe? I found a acidophilus tablet at Walmart that fit the criteria the study used - once you open the bottle it should be stored in the fridge.

I use Spring Valley Acidophilus (2 billion active cultures) in a bottle of 60 tablets for around $12 at Walmart -- or you can get it on Amazon if you can't find it locally. It's cheaper on Amazon, of course - basically half the price of Walmart.

I've passed this information along to my nutritionist and I hope they are recommending all new patients start taking these right after surgery. We want folks to have the best chance at success as possible, right? And if these little pills help produce 10% more weight loss in the early months after surgery, let's all get on board!

~Pam

My Tummy Hates my Vitamins

In the past few weeks my tummy has not been happy with my vitamins. It's the handful of vitamins I take in the morning is causing some yuckiness. One of two things happens after I take 'em. 1) my tummy churns and I feel yucky for about an hour or 2) I get the dry heaves and my body wants to reject the pills I just put in. Either way = bad! My calcium doses sit fine. My bedtime vitamins are fine too. Just the morning stuff. So, I'm sorry to report that because of this strange yuckiness I have been skipping my vitamins more often than I'm comfortable with. I might be hitting a 70% average and that's just not acceptable! What am I going to do? I'm not sure just yet. But I'm putting it out here in the open so I'm accountable and motivated to find a solution. Here are a few thoughts...

• The vitamins I take in the morning are essentially the same as it's always been. So no new stuff that might suddenly cause the issue.
• The only change is the Vitamin A that I'm taking - it's a different brand and type. The old stuff was just a normal pill but the new stuff is "quick dissolve" so it's disintegrating while it's going down. This is the only possible thing that might be at issue, but I can take it alone without a problem, so why would it be a problem when combined with others?
• I started taking glucosamine & chondroitin to help with my knee pain (and it seems to be working, btw) -- but I took that for several weeks before the pukey feeling started, so the probability is low on this one.
• Meals -- it doesn't seem to make a difference if I take the pills with or without food. But since I get the heaving stuff going on, I've been taking them away from food lately.
• I might need to spread things out. My morning pills include 7 different things... so maybe I need to just take 1 or 2 at a time over the course of the morning. Maybe.

So I'll play around with things and see if I can find a solution. If not I'll just have to buck up and do it and quit whining, right? It's medicine, not candy... so I take them whether I like 'em or not. Period.

~Pam

Jennie-O Cracked Pepper Turkey

I had an interesting realization today. Not sure why it took me so long to figure it out... and have no idea why I was thinking about it on my drive to work this morning at 7:30 a.m. But.... since I share everything with ya'll, figured I'd share my random thoughts too.

One scoop of protein powder has about 23-26g protein and about 100-110 calories. Right? Make a shake with milk and fruit and you could easily end up with a protein shake that's 300 calories. Filling, yes. Healthy, yes. Packed with protein, yea. Necessary for new post-ops, yes. It's high quality protein and if you take away the extra calories from milk and fruit, it's a very good comparison for my thoughts....

So I absolutely LOVE Jennie-O Cracked Pepper Turkey Breast sliced in the deli to "medium thick." 


It's one of those foods that I must have in my fridge at all times and is an easy snack or meal that's delicious and nutricious. I love love love this stuff! Seriously. Love it.

Let's compare calories and protein, shall we? For 4oz of Jennie-O Cracked Pepper Turkey you get 24g protein in 100 calories. Whoa! That is equal to a scoop of protein powder, right? And poultry scores at the same level as protein powder on the PDCAAS protein quality rating scale. And 4oz of turkey fills me up and keeps me full for longer than a protein shake does.

I'm not saying that I'll replace my protein shakes with turkey. But I just found it interesting that the nutritional statistics were identical when comparing the two.

Ok... so now you know that I'm crazy, right? At 7:30 in the morning while driving to work 
I'm literally in the car thinking about nutrition labels and ingredients in food. I think I might be off my rocker or something.

~Pam

Not drinking enough

I am on a couple different consumer review boards and I often get asked to fill out surveys on products or about my habits (shopping, electronics, eating, etc.). So right now I'm in the midst of a week long survery about beverages. I have to record everything liquid I drink during the day and fill out a mini survey about each thing. Last night around 11:30 I was completing my daily diary online for what I drank yesterday. Ummm... let's just say that it wasn't pretty. I had my morning chai tea and coffe, then didn't drink ANYthing for the rest of the day until 11pm. Dang! I knew it was a busy day for me yesterday and felt like I was running around like a madwoman all day... but I had no idea I'd done so poorly with my water intake. For weight loss surgery folks, this is completely unexceptable. We don't absorb water in the same way as we used to (most water is absorbed in the stomach, which is now bypassed). So it's important that we stay hydrated and get enough water even if we aren't thirsty. And yes, even when I'm too busy to think straight, I still need to drink my water. Today I NEED to do better. In fact.... not just today, but EVERYDAY I need to do better. ~Pam

A couple things about iron

I was doing a bit of electronic organizing the other day -- yes, I have a million bits of WLS information saved on my computer and a flash drive I carry with me at all times. I came across some info about iron that I wanted to share.

Iron is a mineral that can be found in plants, animals, soil, air, water, meteorites, and rocks, including on the surface of the moon. Here on earth, plants absorb iron through their root systems; animals eat these plants. Humans consume these plants and animals. Many think iron is a heavy metal, which it is not. Iron is an essential micronutrient. Essential used in this way means that the body does not produce the nutrient; micronutrient means that the body only requires tiny amounts to function.

Iron is like money (simple to understand terms)

• Hemacrit and hemaglobin are like cash. It's your readily expendable iron.
• Transferrin is like the armored truck that delivers new cash to the bank from the Federal Reserve.
• Iron saturation is like your savings account of iron. Stored for intermediate use.
• Ferritin is your 401k of iron. It's your long term iron storage.

What is Iron All About Anyway? (a bit more technical explanation)

• Hemaglobin (hgb) - a protein that transports oxygen to the body
• Hematocrit (hct) - proportion of blood volume that is occupied by red blood cells
• Transferrin - a protein that is the major transporter of iron and ideally is saturated with 25-35% iron; when working properly, transferrin binds to iron and transports it to all tissues, vital organs, and bone marrow so that normal metabolism, DNA synthesis, and red blood cell production can take place
• Total Iron Binding Capacity (TIBC) - a measure of the maximum iron concentration that transferrin can bind. Increased TIBC levels may indicate iron-deficiency anemia; decreased TIBC may indicate cirrhosis 
• Ferritin - a protein that acts like a large holding vessel; contains iron that we don't presently need

NOTE: someone who is anemic can still have normal hemaglobin and hematicrit numbers because their ferritin is being depleted in order to maintain those counts. But if the ferritin is in the toilet and no relief comes, the hgb and hct will eventually fall as well. 

Types of Iron

1. Heme Iron - primarily comes from animals/meat. Heme iron is easily absorbed by the body and the best source of iron for people who are iron deficient. Meat, especially red meat is the best source of heme iron. Heme iron can be found in some iron supplements and is the best option for WLS folks.
2. Nonheme iron - primarily comes from plants. This classification represents the majority of iron humans consume in their diets and is the type of iron in most supplements. It is inorganic and is found in grains such as rice, wheat and oats. It's also found in nuts, fruits, vegetables, most iron pills, fortificants, or contaminant iron such as from water, soil or cooking utensils. 

The Iron Rules

(This was posted on OH by a member who has struggled with iron deficiency, this is the system she uses to keep her iron levels in normal range) 

• No multi vitamin or calcium supplement within 2 hours of iron…before or after. 
• No dairy products of any kind within 2 hours of iron. That means no yogurt, milk, cottage cheese, sour cream, cheese, butter...nothing. 
• No coffee or tea within 2 hours. It's the tannic acid, not the caffeine...so not even decaf. 
• Take iron with acid to give it the best possible chance to absorb. 
• Open the capsule or take it liquid form. 

Understanding the Types of Iron Supplements 

Sources: Iron Disorders Institute

The Hour-by-Hour Post-Op Schedule

Just before surgery, in my nutrition training class, we were given an hour-by-hour schedule of when to eat and when to drink and when to have snacks. I started following this schedule and tweaked it a bit as I developed my own routines and habits... but essentially it's the same basic outline that I use today, 2 years later. 


Right after surgery we don't feel hunger and it's very difficult to schedule food and water and get everything in that we need to. It can be overwhelming to watch the clock to calculate the 30 minutes before and 30 minutes after a meal... and only eat for 30 minutes. Then to figure out when to take vitamins and blah, blah, blah. 


So this type of schedule helps us get into a routine with food. 


8:00 - 8:30 -- Breakfast (meals take no more than 30 minutes to eat)
9:00 - 10:00 -- Water - 8oz. 
10:00 - 11:00 -- Snack (protein shake) 
11:30 - 12:30 -- Water - 8oz 
1:00 - 1:30 -- Lunch 
2:00 - 2:30 -- Water 8oz. 
3:00 - 4:00 -- Snack (protein shake) 
4:30 - 5:30 -- Water - 8oz 
6:00 - 6:30 -- Dinner 
7:00 - 8:00 -- Water - 8oz 
8:30 - 9:00 -- Snack (protein shake) 
9:30 - 10:30 -- Water 8oz. 


Eventually I added my vitamins into the routine. This is the schedule I follow today: 


7:00 a.m. --- Breakfast #1 (usually a protein drink) -- Calcium +D 
8:30 a.m. --- Water 
10:00 a.m. -- Breakfast #2 -- Morning dose of vitamins
11:00 a.m. -- Water 
1:00 p.m. --- Lunch -- Calcium +D 
2:30 p.m. --- Water 
4:30 p.m. --- Snack -- Calcium +D 
5:00 p.m. --- Water 
7:30 p.m. --- Dinner -- Calcium +D 
8:30 p.m. --- Water 
11:00 p.m. -- Bedtime (no food) -- Evening dose of vitamins


So if everything is scheduled and needs to happen at a specific time... it's easier to remember.

Coffee and Caffeine

The question comes up a lot on the WLS forums. A lot of people wonder if they can drink coffee after WLS or not. The standard answer is "follow your surgeon's guidelines", of course. And many surgeon's recommend staying away from coffee for the first 6 months to a year - some say it is fine right after surgery... so figure out what the recommendation is from your medical team and follow that advice.
But for those wondering the pros and cons, here's the scoop on coffee and caffeine:

• for some caffeine can be an appetite stimulant
• for some caffeine can be an appetite suppressant
• for some caffeine can cause stomach upset and digestive discomfort
• for some caffeine can promote ulcers or thinning of the lining in the stomach
• for some caffeine aids in gastric motility (keeps you regular)
• for some caffeine can increase heart rates and blood pressure
• in large amounts (over 400mg/day or 32oz brewed coffee) caffeine can cause dehydration
• caffeine can interfere with calcium absorption if taken in large amounts (300mg/day or 20oz)
• tannins in coffee (more so in tea) interferes with iron absorption
• Tannins inhibit B12 as well and there are Anti-Thiamin Factors (ATF) in coffee and tea (caf and decaf) will eat thiamin in the body.  (Thanks to Andrea U. for the information about interfering the B's.)

Knowing all the risk factors and possible benefits is key to making the decision about whether to have coffee regularly or not.

Pam

Vitamin Schedule Confession

Confession Time. I've been lax on my vitamins lately. I hate that I am. I hate that I have to confess it out loud in order for me to figure out how to fix it. I hate that I screw things up sometimes. Why? Why am I doing this? My brain knows how important it is, but it seems like I just don't care as much. Is it the struggle I'm facing with the scale (and it's lack of movement)? Is it the knee and ankle injury that I'm nursing and won't go away which is hindering my exercise enjoyment? Is it some emotional block that's screwing with my routine? I don't know but it is pissing me off. In reality, I have been taking my vitamins. But I've been missing doses too often for my comfort level. It's not like I have just stopped taking them completely - no, not at all. But this morning when I pulled the pillbox out of my purse to refill with today's morning vitamins, I realized that yesterday's morning vitamins were still in there and I didn't even remember that I had missed them. It was a bit of a wake up call for me this morning. All my calcium was gone, so I did good with calcium yesterday apparently. But it is too common that I don't get in all five doses of my calcium. I need to take 2000mg calcium each day and I've chosen to use the Bariatric Advantage Lozenges which are only 400mg per dose. So I need 5 per day. But if I switch to Citrical instead, that's 600mg per dose and I'd only need 3 to 4 doses. A couple nights ago I fell asleep on the couch around 11:00 and woke up around 2am - got up and went to bed. Neglecting the stop in the kitchen for my bedtime vitamins. Nope, it's not that I didn't remember that I needed to take them ... it's that I decided not to. Thought about it, rejected it and just went to bed. Idiot! Little incidents like this finally hit me today as being a BIG deal that I need to face head-on. Confession is good for the soul, right? But fixing it is not really a matter of "Just do it" because obviously that's not working. For several months I've used the text-message-alarm system offered by www.MyMedSchedule.com and it's worked fine. Unfortunately, I seem to be ignoring those little text messages lately. They have simply become part of the background noise of my day rather than a true alarm system that spurs me to action. So here's the plan:

• Turned off the alarm messages from My Med Schedule
• Switch to Citrical calcium pills more often so I require fewer doses throughout the day
• Go back to taking vitamin doses with meals/snacks rather than "every-2-hours"
• When I catch myself "deciding" not to take a vitamin dose, I'll be kicking my own butt

~Pam

Tired of Protein

After WLS one of the biggest pushes in our diets is protein, protein, protein. A typical recommendation for intake is around 80-100g per day. Because we have the gastric bypass issue, we tend to malabsorb some nutrients, so we need more protein than a normal person. That's all fine and dandy. 80-100g of protein a day is a doable amount for most WLS folks who are several months post-op. (It takes a little while to work your way up to this amount when your pouch is tiny and you have trouble eating, of course.) So as ya'll know I've had some issues with my lab results showing low prealbumin numbers. Which means my body isn't absorbing the protein and my body needs a boost. I've been instructed to shoot for 150g protein per day. For someone with a small stomach, that's a LOT of protein. And I really can't do it all from just food so I've had to supplement with protein shakes. Now, remember that I've already done a protein shake every morning already. It's just habit now to start my morning with a protein drink of some sort. Either a fruit smoothie shake, a protein hot chai tea or some other form of drink with the base of a scoop of protein powder. But to get up to 150g of protein I've had to do at least two protein drinks per day plus be super conscious of how much protein I'm getting from food. Let's look at the breakdown of what I need to achieve to hit 150g. Morning Shake -- 30g Breakfast -- 25g Lunch -- 25g Dinner -- 25g Snack -- 15g Evening Shake -- 30g That break down looks pretty easy on paper, right? But what if breakfast is only 15g? That means I need to make up an extra 10g somewhere else in the day. Or what if I don't have a snack in the afternoon - that's another 15g I need to figure out how to get in somewhere else. Or what about last night when I had fish for dinner and it was only 20g and I ate late so my tummy didn't want a protein shake before bed - that puts me 35g short at the end of the day. It's a huge balancing act and after nearly two months of focusing so heavily on protein, I'm really getting tired of the whole routine. I am getting tired of the taste of protein drinks.... so tired that I'm skipping that second scheduled shake at night in favor of something I enjoy the taste of more which doesn't necessarily give me that 30g protein boost. I get a redraw on labs on August 1st (which will probably not happen until Aug 3rd due to scheduling). I just need to hold out on the protein push for another 2 weeks to see if it's working. But what will I do if I find out my labs still suck and I need to continue on the 150g routine? That thought bothers me a lot. I don't want to be rebellious or be a rule breaker but I feel myself going in that direction. I'm trying really hard to keep a positive attitude. ~Pam

My Vitamin D

Christie asked about my Vitamin D. In a recent post I mentioned that I was able to bring my Vitamin D levels up from the low 30's up to 104 in a month. 

Ideally for RNY'ers (and anyone, really) we want our D levels to be up over 80 to realize the most health benefits. Studies have shown that Vitamin D levels below 50 ng/ML indicates that the body is using the Vitamin D as fast as we are able to put it into our bodies. Once we hit that magic number of 50 on our labs, we know the body is finally able to store some Vitamin D for a "rainy day." However, it is also shown that levels over 80 that you see reduced risks of certain cancers (breast, prostate, colon) and a reduced risk of MS. Do a search for Vitamin D Council for more interesting research.

So my D levels have been in the low 30's for over two years now. No matter what I did my numbers just wouldn't come up. So I knew I needed to take some aggressive action to get the number into a healthy range. I let my doctor know what I was planning and had labs scheduled for 4 weeks after I started this new routine. 

DO NOT DO THIS without your doctor's full knowledge, oversight and guidance. I started taking 50,000IU dry Vitamin D3 once per day for 30 days. Now I've backed down on that dose to 3x per week for the next 30 days and will go to 1x per week after that. I'll be retested again at that point. 

When you get a Rx of Vitamin D in the 50,000IU dose, it is Vitamin D2 suspended in a gel capsule filled with oil. After RNY we malabsorb fats, so we need a dry formulation that is water soluble. My pharmacy couldn't get it for me and my PCP didn't have any drug name for the water soluble D3. I bought it from Amazon instead. 

So if you are having issues with chronic Vitamin D deficiency and traditional methods are not working. Talk to your doctor about getting aggressive with your supplementation. But remember that Vitamin D can cause toxicity to the body when taken in doses above what the body needs or can utilize. That is why it is so important that your doctor oversee this type of regimen. 

~Pam

Thoughts on the Food Plan Change

I've given this a lot of thought and here are the things I've considered:

1. My current eating routine is a solid, healthy, well-balanced plan.  I'm strict with my food but not so strict that I feel like I'm living on a perpetual diet.  I know how many calories I eat and what percentage of protein, carbs and fat those calories make up.  I am not sitting around eating Big Macs and large fries.
2. I know my RMR is 1450.  I'm already eating below my RMR which should automatically cause predictable weight loss.  But it's not.  I'm averaging about 1200 calories/day.  
3. I exercise a bunch.  I average about six hours per week.  The Nut says when my workouts intensify with the training program that it will make a dramatic difference in her food recommendations.  But really... those long training sessions are only happening one day a week and the length of the workouts will increase to about two hours of walking instead of one.  So this big jump she's talking about is going from 6 hours a week to 7-7.5 hours a week.  That's not a dramatic jump in my opinion.  So for her to base her advice on my doing minimum exercise seems silly to me. 
4. Her quote of "some days you might only eat 600 calories a day and that's OK" -- this really bothers me.  An active, healthy 185 pound adult should never eat 600 calories a day and especially not on purpose and on a regular basis.  Science dictates that my body NEEDS a minimum of 1450 calories per day just to keep my body functioning.  How can you ignore that science?
5. If I look at her eating plan for meals and consider the higher recommendations of food volume, than I'm not that far off from her recommendations already.  4oz dense protein, 4oz veggie or fruit and 1 starch per meal.  I probably eat more than 4oz of veggie but then don't eat a starch with most meals - otherwise it's pretty close. 
6. She was very adament about my drinking 2 or 3 protein shakes per day.  At 30g per shake, that's 90g.  Plus, add 4oz meat per meal that's another 84g (7g protein per 1oz meat).  That would give me a total of 174g protein per day.  BUT... in the next breath she says "make sure you're getting 60g-80g protein per day."  I wonder if she's ever actually done the math.
7. No food-based snacks allowed.  I can see how this rule would apply if you're drinking protein shakes as your between-meal snacks.  But protein shakes are not dense protein, right?  So if the goal is the keep the pouch full for as long as possible to stave off hunger, then why choose a slider food like a protein shake? My daily schedule dictates that I eat lunch around 1:00 and don't get dinner until around 8:00.  That's 7 hours and I know from experience that a protein shake isn't going to cut it to keep my pouch occupied.  That's why I have a 4:30 snack that keeps me sane until I can get dinner. 
8. No Yogurt.  This ban I can actually understand because slider food doesn't stay in the pouch for very long and you can get hungry again sooner.  So if I have issues with getting hungry, I can see following the advice of not eating slider foods.  But this really is not a problem for me personally.  Is yogurt dense protein?  No.  But it's got 12g of protein in a serving which is pretty darned good.  Am I justifying?  Probably.
9. What if I don't lose any more weight?  What it takes me another two years to lose these last 30-or-so pounds?   Is my brain in the right spot to live in the body I now have?  Am I obsessing about food more than I need to?  Am I expecting too much?  .... all questions for future blog posts, huh?
10. My "Resistance to Change Factor" is pretty high.  I had a former boss who would always refer to the RC Factor in new employees and the need to have a low RC Factor in order to adapt to all the everyday changes.  I guess I need to crank down the knob on this a bit and be more open to changes and trying new things. 
11. I'm taking the PA's advice on the protein increase.  I want my prealbumin number to increase and the way to do that is to get my protein intake up to 150g per day consistantly (I'm already averaging 120g). 

So here's my plan going forward:

7am protein drink

10am breakfast

1pm lunch

4:30pm snack

8pm dinner

11pm protein drink

LOL!  If you have been paying attention to my eating you'll realize that this isn't different.  It's exactly the same as what I've been doing all along.  The only change is actually the 11pm snack is now going to be a protein drink instead of a food snack, but that's not really different because I'd do a hot chai tea as my late night snack half the time anyway.

But I'm going to make a few changes within this schedule.  

Each meal will follow the Nut's plan of:

• 4oz dense protein
• 4oz veggie or fruit
• 1 starch

Breakfast has traditionally been yogurt w/ fruit or Fiber One twigs.  Since I eat breakfast at my desk at 10am, this is convenient and easy.  But I'll have to make a change to the above profile at least for now.   Lunch and Dinner will be pretty much the same as what I've always been eating except I'll have to figure out how to add a whole grain starch with each meal.   My afternoon snack will be, as always, a balance of protein and carbs and will be something filling enough to hold me over until dinner.  And I'll end my day with another protein drink (probably protein hot chai tea, of course). 

Calories??  I really don't know where my calories are going to end up per day.  I'll know more how things pan out tomorrow after I try it for the first time and going forward in the next few weeks as I experiment with different meal ideas.  My goal is to stick with a similar range that I'm at right now (1200-ish) but with 150g protein I might need to bump it up a bit.  I don't want to go with super low carbs simply because I need them for exercise and general good health.  Looking back at my log I seem to average about 100-120g healthy carbs per day, so that seems like a good range to stick with for now. 

And because I know myself and my rebellious nature, I'll continue to take weekends off of planning and tracking.  If I'm too strict with a food plan (any food plan) and I don't have a couple off days thrown in, I know that I'll start feeling confined and restricted and go off on a binge.  So to avoid that, I know I need to give myself permission to NOT count calories.  It's not that I go hog wild and eat everything in sight -- the rule is "eat normally and make healthy choices."  So I'll use this as a way to balance the strictness during the week.

So there you have it.  I'll keep you posted on how it goes.

~Pam

18 Month Post-Op Appointment

Yesterday was my 18 month anniversary. I had an appointment at the bariatric clinic and met with the PA and Nutritionist. There are changes on the horizon and I've still not fully digested everything that was talked about yesterday.

LABS
The PA said that for an 18-month patient that my labs are outstanding! Yeah me! However, there were a few key areas she had concerns about. Enough concern that she's requested a re-draw of labs in 4 weeks after some changes. Her biggest concern was my

Prealbumin - it's too low even though it is within the normal range, she wants it higher. (Result is 24 on a scale of 18-38.) This is a measure of my protein intake and how the body is utilizing it. I already get 120g protein per day. I'm bumping that up for the next 4 weeks to see what that does. (Below I talk about the increase in protein shakes during the day... the lab result is the reason I'm going along with it.)

She also didn't like my Ferritin number. She's having me stop my iron supplements to see if the iron is screwing with the ferritin. This really doesn't make logical sense to me, but I'll do it and see what the results say next month.

I personally am concerned about my Vitamin D. But the response I got was that results in the 30's was typical of WLS patients and they were fine with that number. But from my own research I know that anything under 50 indicates that my body is simply using the supply as fast as I'm taking supplements. It's only after I maintain a level of 50 will the body actually start to store Vitamin D for use later. I'm doing the 50k, once per day regimine for 30 days, then backing off ... I'll have a redraw for Vitamin D next month too. We'll see.

Copper / Zinc interaction. I'm still reseaching this because it doesn't really make sense to me - but the Nut said that I need to keep my zinc and copper doses far apart from each other. So I'm now taking zinc in the morning, copper at night. Somehow they interfer with each other, but I need to understand this better before I'm convinced its true.

EDITED: Yep, copper and zinc don't like each other - so I'll separate the doses as recommended.

FOOD
This is where the big changes are happening. I know I've posted about my nutritionist before and I'm not always thrilled with her advice. In fact, the advice I got yesterday is the exact same advice I've gotten since I was 2 months post-op. As you all know I've been struggling with really, really slow weight loss. Since August last year I've lost 15 pounds and 5 of those pounds came off in the past 4 weeks. So in an attempt to figure out how to make me lose weight faster and have a "more predictable" amount of loss, the Nut has suggested going back to the same plan I was suppose to be following when I was 2 months post-op. Here's the plan:

• 8am - breakfast
• 2-4oz dense protein
• 1/4-1/2 c. veggie/fruit
• (suggested meal: 1-2 egg veggie/cheese omelet and 1 slice melba toast)
• 9am -12:30pm - fluid time
• 16oz water
• 8oz protein drink
• 1pm - lunch
• 2-4oz dense protein
• 1/4-1/2 c. veggie/fruit
• If not full... 1 additional side item (veggie/fruit/starch)
• (suggested meal: wrap sandwich w/ 1oz turkey, 1oz cheese, lettuce on 1/2 tortilla)
• 2pm - 5:30pm -- fluid time
• 16oz water
• 8oz protein shake
• 6pm - dinner
• 2-4oz dense protein
• 1/4-1/2 c. veggie/fruit
• If not full... 1 additional side item (veggie/fruit/starch)
• (suggested meal: 1-3oz grilled chicken, 1/4-1/2c steamed broccoli, 1/4-1/2c cantaloupe)
• 7pm - bedtime - fluid time
• 12oz water
• 8oz protein shake
• 2 popsicles

Ok, so my Nut wants me to change things up and give a new eating plan a try for two weeks. (EDITED: I'm re-thinking this... might not try it, we'll see.)  

She's banned yogurt and any slider foods (even though I didn't complain about getting hungry after a yogurt meal.) I'm not allowed food-based snacks anymore, she wants all snacks to be a protein shake instead. She said some days I might only get 600 calories, but some days might be 1100... and that was just fine, but to worry about portion size rather than calories or nutrient grams. (Even though I don't believe I have any issues with staying within my portion size requirements and if I don't eat enough calories, I know my body revolts and I have a tendency to binge on crap.)

At one point she asked me: "Can you eat 2-ounces of dense protein AND 1/2 cup of vegetables in the same meal?" .... as if my pouch was still 1-ounce in size and that eating 4-ounces at a single meal might not be possible for someone who is 18 months post-op. I was flabergasted, of course, because the amount of food I eat now (8-10 ounces/meal) is expected and typical of someone at my stage. How can she not know that?

EXERCISE 
So the Nutritionist also said my exercise routine wasn't anything out of the ordinary and simply met the minimum recommendations. I am now doing 6 days, 60 minutes per day. Apparently the minimum recommendation is 4-6 days per week, 30-60 minutes each. So even if you're at the top end of the scale, it's still only the minimum apparently. "When I start doing more," then I will need to adjust my eating to accomodate the added exercise. (Meaning when my half-marathon training keeps me on the road for more than 60 minutes per session.) Life is not "The Biggest Loser." Normal people don't have 4 or 5 hours every day to spend in the gym. It's very difficult for me to understand that 6 hours of exercise a week -- walking/running 25-30 miles a week -- is not enough to be more than the minimum expectations.



What's Next?
I've got some thinking to do. Planning and rearranging. And I need to figure out how to have peace with some of the stuff the Nut has told me and advised me to do. I need to do some research on the vitamin and mineral stuff to see how true the information is that I've been given. I need to come up with a food plan that I can live with that won't make me feel like I'm on a diet. Thankfully I have yoga class this afternoon. At least that will give me the chance to focus on my center... relax a bit and let all these issue melt away for an hour.

~Pam